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CONTRIBUTIONS TO MIDWIFERY, 



AND 



\mm$ flf Mamm attir C|tlto, 



WITH A 



REPORT ON THE PROGRESS OF OBSTETRICS, 



AND 



UTERINE AND INFANTILE PATHOLOGY IN 1858. 



BY 



E, NOEGGERATH, M.D., AND A. JACOBI, M.D. 



ajlSM 



/itt?i- 



NEW YORK: 
BAILLIERE BROTHERS, 440 BROADWAY; 

LONDON :— H. BAILLIERE, 219 REGENT STREET ; 

PARIS :— I. B. BAILLIERE, ET FILS 19 RUE HAUTEFEUHXE ; 

MADRID: — C. BAILLY BAILLIERE, 11 CALLE DEL PRINCIPE 

LED7ZIO:— B. WESTERMANN & CO. 

1859. 



WQ 
1853 

rUmno I 






Entered, according to Act of Congress, in the year 1859, by 

BAILLIERE BROTHERS, 

In the Clerk's Office of the District Court of the United States, for the Southern District of 

New York. 



THOMAS HOLMAN, PRINTER, 
Corner of centre and white streets, n. t. 



PKEFACE. 



Diseases of women and children have, in the last century, re- 
ceived great attention from physicians, both on this Continent and 
in Europe, and so much has been written of late upon this branch 
of our science, that an author or student of the present day is at 
a loss how to make himself acquainted with all that exists on 
the subject. This difficulty is increased by the absence of a jour- 
nal giving a knowledge of previous works on uterine and in- 
fantile pathology. Although we are in possession of very valu- 
able retrospects on medicine in general, it must be admitted that 
their tendency and size are such as to exclude anything like com- 
pleteness. While in the books referred to, general pathology of 
so-called internal and surgical diseases is treated of at sufficient 
length, the chapters on obstetrics, uterine and infantile pathology 
are dealt with in a rather off-hand manner. The necessity of a 
book, intended to supply this want, will be readily understood by 
every one who feels a desire to make himself acquainted with the 
progress of science, but more particularly to those of our brethren 
who feel called upon to write articles of their own. In preparing 
this book, we were more and more impressed with the truth of 
this remark. A perusal of our periodicals reveals a frightful 
state of ignorance as to what has come before, and thus a vast 
amount of labor is wasted by the publication of so-called new 
facts and theories, which might be more usefully employed, if the 



IV PREFACE. 

books, already there, were more generally known. This was, 
hitherto, a very difficult task, because we were in want of a book 
which should contain the essence of all that is dispersed in hun- 
dreds of publications, written in a great variety of languages. In 
preparing a work of this kind, we have endeavored, at least, to 
give an account of every original article, or monograph, that appeared 
to be of any importance ; while we have tried also, to men- 
tion, at least, the headings of those of less value, or beyond our reach. 
From 1858, we intend to keep up a review of every successive 
year, especially with regard to German literature, provided that 
it should meet with the approval of the profession. 

The report is preceded by a number of original articles, which 
will, we think, repay a perusal. 

E. NOEGGERATH, M.D., 

A. Jacobi, M.D. 
50 Amity Street, N. Y. 



PART I. 



CONTKIBUTKMS TO MIDWIFEKY, 



AND 



leasts of tDomen anir <!ll)itfn:m- 



CONTENTS 



Page. 

Art. 1.— Three Cases of Induction of Premature Labor, performed in New 
York, after Cohen's Method. With Remarks. By E. Noegoerath, 
M.D 9 

Art. 2.— Four Cases of Injection of a Caustic Solution into the Cavity of the 
Womb, illustrative of the Advantages and Dangers connected with 
this Proceeding. By the Same 24 

Art. 3. — Remarks on the Employment of Pessaries ; with the Description of a 

New Instrument. By the Same 36 

Art. 4.— A Contribution to the Pathogenesis of Uterine Polypi. By the Same. 48 

Art. 5.— Invagination of the Colon Descendens in an Infant j with Repeated 

Hemorrhages in the Colon Transversum. By A. Jacobi, M.D 51 

Art. 6.— On the Oxysulphuret of Antimony as an Expectorant in Inflammatory 

Diseases of the Infantile Respiratory Organs. By the Same 59 

Art. 7.— On the Etiological and Prognostic Importance of the Premature 
Closure of the Fontanels and Sutures of the Infantile Cranium. By 
the Same 70 



ARTICLE I. 

Three Cases of Induction of Premature Labor performed in New 
York after Cohen's Method. With Remarks by E. Noeggerath, 
M.D. 

When I published my first case of induction of premature labor 
performed in this city, I said : " The time will come, and is rapidly 
drawing near, in this country, that the average number of labors 
ending naturally, without operative assistance, will lessen, in a 
remarkable degree. The immense immigration of a far from 
wealthy and well-shaped people on the one hand, and the strong 
tendency to high city life on the other, must show their influence 
upon the coming generations." Two years have elapsed since the 
above was written, and in this short period I have had ample 
occasion to see the truth of my former remarks exemplified. I 
have to add an account of two other cases in which Dr. Cohen's 
method was successfully employed — a method, the full value of 
which I desire to demonstrate to the profession. I hope to see 
the day that it will supplant the douche, rupture of the membranes 
and ergot in America, England, and France, as it is doing in 
Germany. 

* Case 1. — Mrs. G. M., born in Germany, living now in New 
York, presents, in her external appearance, the form of a healthy, 
well-shaped female, though she is of a rather short stature, and 
exhibits, on a closer examination, the well-known form of knock- 
kneed rhachitic lower extremities. 

In her first confinement, which took place about fourteen months 
ago, she was attended by Dr. G. C. E. Weber. This eminent 
practitioner was compelled, to perform the operation of craniot- 
omy, in consequence of the malformation of the pelvis. He 
advised her then to be delivered artificially, before the full 
term, in case of a second pregnancy, not only for her own safety, 
but because it would afford a chance of her having a living child. 
The latter circumstance being of considerable importance, induced 
the lady to follow the advice of her physician. Conception again 
took place at the end of October, or the beginning of November, 

* New York Journal of Medici?ie, for July, 1856. 



10 

1855, for, at that period, her courses, always regular, ceased. She 
expected, therefore, to be confined during the first week of August, 

1856, with which statement we could thoroughly agree upon a 
first examination made towards the end of May. The superior 
margin of the fundus uteri was then found between the umbilicus 
and the processus xiphoides, the womb being equally developed 
on both sides. The fcetal pulsations we could easily observe on 
the right side, at a level with the umbilicus, while the feet were 
distinctly felt near the left upper portion of the uterus. Corre- 
sponding results were obtained by a vaginal exploration. The 
pregnacy was decided to have advanced to the end of the eighth 
lunar month, with a large-sized living child, having a cranial pre- 
sentation. 

The pelvis was a model of rhachitic deformity. The promontory 
of the sacrum protruding forward and towards the left side of the 
pelvic cavity, diminished the antero-posterior diameter to 2|-2^ 
inches, while the lateral diameter remained unchanged in extent ; 
the outlet of the small pelvis was rather enlarged in consequence 
of the widely open pubic arch and the flattening of the sacral 
curvature. The whole basin presented but a very small degree of 
inclination. The general state of health of the patient was satis 
factory. On Monday, 2nd June, about 11 o'clock in the morning, 
Dr. G. C. E. Weber and myself proceeded to perform the opera- 
tion of inducing labor after the method of Schweighauser, Cohen. 
The woman was placed upon her back with the nates projecting 
somewhat over the edge of the bed, and the feet supported by 
two chairs ; an elastic catheter, of the ordinary size, was intro- 
duced into the mouth of the uterus, and pushed upwards, with the 
intention of bringing the instrument between the anterior wall of 
the uterus, and the fcetal membranes ; — the point of it entered the 
womb to the extent of about four inches — then, with a syringe 
adjusted to it, we injected about seven ounces of water, heated to 
90° or 100° Fahrenheit. As soon as the fluid touched the internal 
surface of the uterus, the woman complained of uneasy feeling in 
the abdomen, and we distinctly felt the uterus in a state of rigidi- 
ty, which lasted for several minutes. After a time, the finger was 
removed from the external opening of the catheter, when a portion 
of the water was rejected through the instrument with considera- 
ble force. The withdrawal of the tube was followed by another 
escape of some water. During the following thirty minutes, the 



11 

uterus was in an almost continual state of contraction with but 
very few and short intermissions of flaccidity. Besides a slight 
degree of excitement and little headache, the woman's state of 
health, as well as her pulse, proved to be unchanged. Towards 
noon the pains grew stronger, but less in frequency, with longer 
intervals. 

At about seven o'clock in the night, the pain lessened in a de- 
gree that we thought it proper to make another injection. This 
was applied in the same way with the exception that we did not 
change the ordinany position of the patient in her bed, because 
the lips of the os uteri were already so much retracted by the pre- 
vious pains, that the introduction of the catheter would meet with 
no difficulty at all. Whether the water was injected with a some- 
what greater force than at the first time we cannot decide, but it 
all remained in the uterus, and the operation was followed by 
a sudden enlargement of the womb. Mrs. M., experienced a very- 
distressing pain in her abdomen ; much more so than she did at 
the former injections. It made such an impression upon her sys- 
tem that she fell into an almost unconscious state ; the pulse sunk 
suddenly, so as to be scarcely perceptible ; her face instantly 
became purple, and her breathing very much embarrassed. Half 
an hour later, when she recovered from these symptoms, she was 
seized with a violent chill, which lasted for nearly two hours. This 
was followed by a feverish condition, general heat, and a pulse of 
130 in a minute. This alarming state gradually subsided, and a 
renewed succession of strong uterine contractions commenced. At 
seven o'clock. A. M., of the following day, we were told that she 
endured almost incessant and very severe labor pains during the 
last night. At this time we found that the vaginal cervix had 
disappeared completely, the os uteri was opened to the size of a 
silver dollar, the well-filled bag protruded into the vagina with 
every recurring pain. Now we could ascertain, beyond question, 
a vertex presentation. At nine o'clock, A. M., the os uteri dilated 
to its full extent, and the membranous cyst broke while it was 
protruded almost to the external orifice. At that time, the vertex 
was just engaged in the entrance of the pelvis. Passing over the 
very interesting peculiarities of this cranial parturition, it will be 
sufficient to say, that it required a full hour of time to bring the 
head down through the brim of the small pelvis, notwithstanding 
those tremendous paius, which are only witnessed with rhachitic 



12 

females. But when the greatest circumference of the cranium had 
passed the upper part of the pelvis, then one of these violent pains 
was sufficient to drive the head through the whole cavity, and at 
once out of the labia externa up to the shoulders. The entire 
paturition, from the time of the first injection, was achieved in less 
than twenty-four hours. 

The child, though born in a weak condition, was soon brought 
to the most satisfactory state of breathing and crying. After the 
placenta was removed by the ordinary manipulations, the uterus 
proved to be well contracted. The mother's condition was satis- 
factory, and has continued favorable. 

Case 2. — Mrs. L — ■ , of Sixth Avenue, New York, born of 

a German mother, who, although of a very small stature, lived to 
the age of sixty in average good health, and died rather suddenly 
from a disease of the chest. The only sister of our patient went 
through several easy confinements. Mrs. L., had the first men- 
strual flux when eighteen years old, and this continued regular up 
to the time of her marriage, which occurred in January, 1855. 
She soon became enciente, and was taken in labor in February, 1856. 
Dr. Michaelis, who attended her on that occasion, recognized a 
contraction of the pelvis and a cross presentation of the child, its 
head being situated near the left iliac region ; thirty-six hours 
after the beginning of labor, Dr. M. turned the child by the feet, 
extracted it, and delivered the head by means of a forceps. The 
child died during this series of operations. The mother recovered 
promptly. On March 7, 1857, Mrs. L. fell in labor with her 
second child, and was attended by Dr. S 1, who tried to de- 
liver the child by a forceps operation, but could not succeed, 
owing to considerable contraction of the pelvis. Aaother phy- 
sician was called in to assist, and finally a dead child was deliv- 
ered by the forceps. Thus the mother's hope of having a living 
offspring was twice blighted. During her next pregnancy, she 
learned from her acquaintances that she might have a living child 
by being delivered at a time prior to the full term, and she was 
at once resolved to try her chances. With a view of having pre- 
mature confinement induced, she applied to Dr. Krackowizer, 
and to no worthier man could she have trusted her own life and 
that of her child. This gentleman, to whom I am indebted for 
the particulars of the case, invited me to see Mrs. L. in consulta- 
tion. We met at the patient's residence, June 26, 1858, and 



13 

learned that she was last unwell at the time ol the Jewish New- 
Year (September 19, 1857), and that she quickened near the end 
of February, 1858. The woman was of dark complexion, and 
very short of stature, measuring from head to feet only four feet 
six inches, the bones of the entire skeleton being rather short and 
massive, more especially the epiphyses. From the strong inclina- 
tion of the pelvis, the lower part of the backbone stands out in a 
remarkable way, while the lumbar portion of the vertebral column 
is apparently curved in a forward direction. The measurement of 
the pelvis with Baudelocque's calipers presented the following 
data: 

Distance of both spinae anter. sup. . . 9| inches. 

" " trochanters, .... 12 " 
External Conjugata, . . . . 6£ " 

Conjugata, 3| " 

By internal examination the promontorium could be easily de- 
tected, it being directed somewhat towards the right side of the 
pelvis, thus allowing a larger space for the left pelvic exca- 
vation. The os tineas was directed considerably backwards, 
almost touching the os sacrum, both external and internal orifices 
permeable to the finger ; laquear vaginae empty, head found float- 
ing towards the left iliac region ; lower part of the pelvis and 
outlet spacious ; uterus considerably anteverted. 

Thus we had to deal with a markedly rhachitic pelvis, and an 
antero-posterior diameter of the brim of three inches and odd 
lines. This disposition, taken together with the history of her 
two previous confinements, induced us to comply with her wish to 
have premature labor induced as the only chance of having a 
living child. She, therefore, was placed across the bed, the feet 
being supported by two chairs. By gently pushing the fundus 
uteri backwards, the os tineas was brought more fully in a direc- 
tion corresponding with the axis of the pelvis, and an elastic 
English catheter, with a metallic mandrin was introduced into the 
cavity of the womb, between its anterior wall and the membranes, 
as far as one and one-half inches, as it was impossible to push it 
any further without using considerable force. Through it about 
three ounces of warm water were injected and instantly expelled 
beneath the instrument. This was repeated with the same result. 
We now withdrew the catheter and introduced it again in a 
somewhat different direction. By this manoeuvre, the catheter 



14 

could be introduced considerably further upwards, and the full 
amount of the injected water was retained. Immediately after 
this, the uterus became hard and rigid, and the patient had to 
press downwards as if in labor pains, which lasted for about half 
a minute. The patient was now ordered to rise and walk about 
the room. No water was discharged. From half-past nine, A. M., 
June 8th, when the first injection was made until half-past ten, 
A. M., she experienced four well-marked though feeble pains. 
From this time up to half-past nine, P. M., regular labor pains, 
increasing in strength and rapidity of succession, were observed, 
and with almost every one of them a small quantity of water was 
discharged. Still their influence upon the os uteri was as yet very 
insignificant, being dilated to about the size of a two shilling 
piece. Towards midnight the pains grew very strong, and at 
about three, A. M., a large quantity of water was discharged with 
one forcing pain. Dr. Krackowizer saw the patient at four, A. M., 
and 'found the right scapula presenting (in front), head towards 
the left side ; foetal pulsations easily perceptible on the left side 
of the abdomen below the umbilicus. The patient was placed 
under chloroform, when the doctor turned the child by one foot 
and extracted it, except the head. The operation of turning was 
attended with some difficulties, and could not be performed as 
quickly as was desirable. The head itself proved too large to be 
extracted in the usual way*, and consequently the forceps was 
applied, and thus the child was delivered. It proved to be still- 
born, and, although every effort was made to revive it, life could 
not be restored. The mother did perfectly well anpl was up after 
the ninth day. 

From the appearance of the child it became evident that the 
gestation was more advanced than we supposed, from the account 
given by the parents, or from the results of the obstetric examina- 
tion ; the peculiar displacement and formation of the uterus hin- 

inches. 



dering a fair estimate. 




Full length of the foetus, 


. 16 


Lateral diameter of the head 


. 3 


Antero-posterior, .... 
Vertical, 


4 
. 4 


Long diagonal .... 
Distance of shoulders, 


. 5 


" " trochanters, . 


. H 



15 

Case 3. — In July last I was called to see Mrs. N., of Sullivan 
Street, in consultation with Dr. Shnetter, of this city. Here I 
found a lady confined to bed for the last three weeks, and unable 
to walk more than a few steps, owing to an cedematous swelling 
of her almost entire body. Both legs were swollen, and stiff 
with serous effusion as high as the abdomen, as also her arms and 
face. The urine tested by heat and nitric acid, became instantly 
thick, giving a very copious sediment, consisting of albumen. 
The microscopical examination conducted previously by Dr. 
Shnetter, confirmed the chemical analysis-; numerous fibrinous 
casts, as well as epithelial cells from the kidneys, filled with a 
fatty detritus, having been detected by this gentleman. We 
therefore considered Mrs. N. suffering from far advanced degen- 
eration of the kidneys and consequent anasarca. From her pre- 
vious history, it appeared that similar symptoms, although in a 
less remarkable degree, had occurred in a former pregnancy, and 
she had been taken with eclamptic convulsions at the time of her 
last labor. She was now about six months gone, and we most 
naturally concluded, that if pregnancy was allowed to proceed 
up to the full term, she would not only be subject to eclampsia, 
but it even seemed more than probable, that the disease, advanced 
as it was, would gradually undermine her system, or destroy her 
by a sudden attack of oedema pulmonum or pericardii. It was, 
therefore, resolved to interrupt pregnancy as the only chance of 
saving, or rather prolonging her life. At five o'clock in the after- 
noon, we introduced an elastic catheter between the membranes 
and the walls of the uterus, about four inches, and injected five 
ounces of tepid water. No reaction took place at first, and it was 
not until two hours after the injection was performed, that the 
patient was taken in labor. From this time the pains came on 
slowly, but steadily, and, during the night, effected a gradual 
dilatation of the os. At about nine o'clock, A. M., on the follow- 
ing morning, the os was fully dilated. Upon rupture of the mem. 
branes, the child presented with the back, when Dr. Shnetter 
turned and extracted a small immature foetus, which expired after 
a few ineffectual efforts at respiration. The mother advanced 
very slowly towards recovery, but she finally convalesced, and is 
able again to attend to her household duties. 

These are the three cases of induction of premature labor per- 
formed—after Cohen's method, in the city of New York. The only 



16 

case on record, where this method was made use of in the United 
States, is that of Dr. Blatchford, an account of which was read be- 
fore the Eensselaer County Medical Society, at the Semi- Annual 
meeting, January 7, 1850, and published in the New York Journal of 
Medicine, N. S., Yol. IV., No. II., March. 1850. It was pel- 
formed at the seventh month of gestation, on account of con- 
tracted pelvis. We give a condensed extract from Dr. Blatch- 
ford's valuable paper. 

Mrs. M. has been delivered twice with the perforator, be- 
cause the pelvis was so contracted in all its diameters, that 
the children could not be removed alive with the forceps. 
Therefore, on Wednesday, 5th of December, ten o'clock, A. M., 
being just seven months since she was last unwell, and two 
and a half since she quickened, everything being in readiness, 
with the assistance of Dr. Bobbins, half a pint of " tar water " 
was injected into the womb through a large sized male catheter, 
moderately curved, and by means of the syringe of a common 
self-injecting apparatus. The catheter passed without the least 
resistance from two to two and a half inches within the uterus, oc- 
casioning not the slightest pain. After remaining about ten 
minutes in a recumbent posture, she was permitted to get up, 
which she did, and moved about the house as usual, experiencing 
no other inconvenience than a constant draining from the vagina, 
of a small quantity of a fluid slightly tinged with blood, and 
tainted with tar, and a sense of weight, as if, to use her own ex- 
pression, " the child had settled down." Nothing unusual oc- 
curred until Friday evening, the seventh, when she was suddenly 
taken with a chill and rigor, which lasted nearly two hours, 
accompanied with severe headache. It was succeeded by slight 
fever. Saturday morning she was very comfortable, with the ex- 
ception of the slight draining before mentioned. At eleven 
o'clock, however, and after the operation of a carthartic pre- 
viously given, she was taken in labor. The pains at first were few 
and far between, until about one o'clock, P. M., when they became 
quite violent and frequent. At two o'clock the membranes gave 
way during a hard pain, and a very large quantity of water was 
discharged. The effect of this large evacuation was, to give 
almost entire relief from pain. By a little after eight o'clock, 
Sabbath morning, her pains again returned, and they soon became 
very regular, but it was not until noon that dilatation could be 



17 



said to have fairly commenced ; by eight o'clock, the head could 
be felt forcing its way through the upper strait. From this time 
until about one o'clock the pains were very severe, and yet very 
little progress had apparently been made toward the completion 
of labor. The patient, hitherto firm, began to manifest signs of 
restlessness and impatience, and her spirits evidently began to 
flag. Still Dr. Blatchford left the case to nature, and at half-past 
two, A. M. (113 hours from the time the tar water was injected) 
she was delivered of a plump and vigorous child, loudly vocifer- 
ating its own advent. It weighed nearly four pounds ; the 
placenta soon followed. The mother recovered without any un- 
pleasant symptoms whatsoever, and had the satisfaction of nursing 
her own infant. 

From an analysis of these four operations performed in the 
United States, or rather in the Empire State, the following table 
may be drawn : 



AUTHORS. 



Blatchford. 
Noeggerath 
Noeggerath 
Noeggerath 



Number of 
Injections. 



Time of Labor 
after first 
Injection. 



113 hours. 
23 hours. 
19 hours. 
16 hours. 



Fate of 
Children. 



Alive. 
Alive. 

Dead. 

Died soon 
afterbirth. 



Fate of 
Mothers. 



Recovery, 
Recovery, 
Recovery. 
Recovery. 



Reason for 
Operation. 



Contracted 

pelvis. 
Contracted 

pelvis. 
Contracted 

pelvis. 

Morbus 
brightii. 



REMARKS. 



Cranial present- 
ation. 
Cranial present- 
ation. 
Cross presenta- 
tion. Turning. 

Cross presenta- 
tion. Turning. 



This limited number of observations is, of course, insufficient for 
a final discussion with regard to the value of the method, but 
added to the statistics already known, they will throw additional 
light upon the operation, and tend to determine its true position. 
The first man who conceived the idea of inducing premature labor 
by injection of witer into the uterus, was Dr. Tac. Fried. 
Schweighauser, of Strassburg. In his excellent work, " Das 
Gebdren nach der beobachteten Natur" etc., Strassburg and Leip- 
zig, 1825 ; he recommends to throw a quantity of warm water 
into the womb for that purpose. But, as he never seems to have 
practiced it, we must attribute the whole merit to Dr. H. M. 
Cohen, of Hamburg, who first introduced this proceeding into 
practice. He called the attention of the profession to this method 
in a thesis written in the year 1846. Since this time, we have 



18 

through the different medical journals, accounts of upwards of 
sixty cases in which Dr. Cohen's directions were imitated, all of 
which are very favorable to the operation. From a perusal of 
monographs and periodicals, I have been able to collect sixty-two 
cases (Birnbaum, seven ; Crede, three ; Cohen, seven ; Steitz, 
ten ; Naegele, one ; Harting, two ; Kilian, two ; Ritgen, one ; 
Germann, nine ; Strauss, one ; Riedel, six ; Krause, one ; Wag- 
eninge, one ; Snoep, two ; Potonnier, two ; Viguier, one ; Stein- 
brenner, one ; Scanzoni, one ; Blatchford, one ; Noeggerath? 
three). With regard to the time from the first injection and the 
termination of labor, the shortest period was noticed by Potonnier, 
viz., three hours ; the longest occurring in one of Steitz cases, viz.» 
eight days ; two days being the average time. The only instance 
where this method failed, was recorded by Scanzoni (Langen- 
heinrich). This case is published in " Scanzoni' 's Beitragen zur 
Geburtskunde" Vol. II. ; Wurzburg, 1855 ; Article IV., Mitthei- 
lungen von der geburtshilflichen .Klinik in Wurzburg, von Dr. 
Langenheinrich ; page 50. But from a careful perusal of this^ 
case, it appears that the method was not subjected to a fair trial, 
the catheter being introduced into the womb two inches, where 
its further progress was arrested by an unknown obstacle. The 
water was rejected instantly, as might have been expected, from 
the fact, that the catheter was not introduced high enough. All 
authors agree that a considerable portion of the water has to be 
retained within the womb, to make sure of efficient labor pains. 
The same thing happened in the second of our cases reported, and 
if we had not persisted in finding out a region where the catheter 
could be safely introduced as far as four or five inches, we should 
certainly have failed. All the mothers recovered, except three, 
which, however, died from diseases unconnected with the opera- 
tion, viz., two from eclampsia ; one from puerperal fever. The 
fate of the child we find noted in fifty-eigh# cases, thirty-six of 
which were born alive, and eighteen dead ; the number of deaths 
corresponding pretty accurately with the number of cross pres- 
entations. 

Let us now endeavor to compare these results with those of 
other methods. It would be a waste of time, to discuss anew the 
value of puncturing the membranes. What accoucheur would 
not prefer a method by which the membranes remain intact, thus 
avoiding all the trouble, and all the danger, connected with a dry 



19 

labor ? And as to ergot ? I think no unprejudiced accoucheur 
will now resort to this remedy, with a view of inducing prema- 
ture confinement, partly on account of the uncertainty of its opera- 
tion (one failure in every fifth case, Krause), and partly on 
account of its generally admitted poisonous influence upon the 
foetus. This remedy has had its day, and it ought now to be men- 
tioned only from a historical point of view. The dilatation of the 
os uteri, by compressed sponge (Kluge's method) has met with 
invincible obstacles in many cases. In some instances, a sufficient 
dilatation of the os uteri was effected, but no pains followed ; 
cases of this kind have been reported by Houbeau, Jaesche, 
Jacoby, and Barnes, and altogether about eighteen cases are re- 
ported where other means had to be employed, as the action of 
the sponge proved to be insufficient. Moreover, the application 
of compressed sponge is tedious both to the patient and the 
accoucheur. The same may be said of Busch's instrumental dil- 
atation, and the method of Hamilton and of Kiecke. The plug- 
ging of the vagina with scraped linen (Scholler), or with an 
animal bladder (Hiiter), or with the colpeurynter (Braun) are, 
doubtless, more safe than the methods just mentioned, but alto- 
gether not free iom inconveniences. The best of these con- 
trivances is Dr. Braun's caoutchouc bladder-plug. Still, some 
cases are reported where it was unable to produce pains. Its 
chief drawback is the irritation of the vagina, and lower section 
of the uterus, in consequence of its application. Thus Professor 
Breit, of Tubingen, has published the case of a woman who died 
from inflammation of the internal genital organs effected by the 
colpeurynter. But for controlling haemorrhage, and promoting 
labor in cases of placenta praevia, the bladder-plug will always 
remain the remedy par excellence. Scanzoni's methods of in- 
ducing premature confinement by irritation of the nipples, or by 
irritation of the vagina and uterus, with carbonic acid, have met 
already with a number of failures counterbalancing entirely the 
amount of success obtained by them. The methods of Drs. Simp- 
son, Merrem, Lehmaun, Krause, which are intended to effect 
labor, by the introduction of a sound, or a catheter with immedi- 
ate removal, or with a view of leaving the instrument in the 
uterus, seem to be simple and effectual remedies for this purpose. 
But very few cases are reported in which they failed. Dr. 
Braun's latest proposition (see our report), seems to be invented 



20 

for the sake only of making a new invention. He proposes to in- 
troduce a gut-string between the membranes and the inner surface 
of the uterus, the effect of which proceeding is certainly no other 
than that obtained by Krause's method. The use of Galvanism 
(Radford, Simpson, Mikschik) is often very painful, not certain in 
its results, and tedious for the accoucheur, even should he happen 
to be in possession of an electro-galvanic apparatus. 

Before entering upon a discussion of the position which ought 
to be assigned to the douche, we will briefly mention a case in 
which this remedy was used without making the least impression 
upon the pregnant uterus. The woman to whom we refer was 
received into the lying-in hospital of Bonn, enciente with her first 
child, and at about seven months. She was of small rhachitic 
stature, and, although her spinal column was pretty straight, she 
measured not more than about four feet ten inches. Her pelvis 
was, therefore, not spacious and a pretty fair specimen of pel- 
vis justo minor, with an antero-posterior diameter of three and 
three-quarter inches. Under these circumstances, it was thought ad- 
visable not to let her go the full term, and the douche was select- 
ed for exciting labor pains in the thirty-sixth or thirty-seventh 
week of pregnancy. We had a large douche ascendante, which 
threw a powerful stream of water from a hight of twelve feet. 
The basin on the top of it was filled with hot water (100° F.), and 
I directed the nozzle of the tube as near as possible towards 
the os tincae. In this way the water was allowed to play against 
the lower segment of the womb twice a day for fifteen minutes, 
and this application continued for a full month. This douche was 
applied at least fifty-six times, but in vain ; not the slightest im- 
pression could be made upon the uterus, and not the least indica- 
tion of uterine contraction could be obtained from beginning to 
end. She, therefore, was left alone till her full time, and as she 
had an exceedingly small child, and very strong pains, she was 
delivered even without the aid of the forceps. 

But this is not the only instance of this kind. Dr. Krause, in 
his elaborate treatise on induction of premature labor, notices 
thirteen cases in which the douche was insufficient to effect labor 
(Scanzoni, three ; Kowalsky, two ; Michaelis, Grenser, Ziehl, Kil- 
ian, Ritgen, Goudoever, Dubois, Levy, each one), and not a few 
cases are mentioned where thirty to seventy applications were 
required to induce efficient pains (Diesterweg, Germann, Grenser, 



21 

• 

Arneth). We are in possession of accounts of about ninety-four 
cases in which the douche was used (Kiwisch, seven ; Chiari, Gren- 
ser, each six ; Harting, Diesterweg, Levy, each four ; Arneth, 
Busch, Kilian, Germann, Birnbaum, Scanzoni, Simon ' Thomas, 
Dubois, Kowalsky, Elliot, each three ; Klein, Stengelmaier, 
Trogher, Lanz, Braun, Smith, Simpson, each two ; Betschler, 
Mikschik, Ziehl, Michaelis, Ritgen, Rendlen, Ludwig, Lacy, Skel- 
eton, Atthil, Sinclair, Goudoever, Aubinais, Bourgeois, A. K. 
Gardner, Noeggerath, each one). Of this number, fourteen mothers 
sickened during the application of the douche — i. e., one was 
taken with nausea, two with vomiting, three with haemorrhage, 
one with violent diarrhoea, two with vaginitis, two with metritis, 
three with fever ; out of these ninety- three women, in whom the 
douche was applied, twelve died in childbed. This is a number 
unparalleled in the history of induction of premature labor. From 
eighty cases in which ergot was used, only three women died ; from 
one hundred and thirty-five cases of induction of labor by tapping, 
eleven died ; from ninety-six cases of intra-uterine injection, three 
died — viz., two from eclampsia, one from puerperal fever. Out of 
these eleven cases of death after application of the douche, six were 
owing to metritis. We are inclined to believe that some, if not 
all, of these metritides were caused by the douche itself. It is 
right to suppose that the congestion produced and constantly re- 
peated by the act of throwing a full stream of warm water, as often 
as thirty or seventy times, in an interval of a few weeks, against 
the uterus, will at last become stationary, and pass through the 
different stages of an inflammatory process. It further appears 
from a perusal of the facts stated above, that the douche cannot 
be relied upon when applied for the purpose of inducing prema- 
ture labor ; it proved insufficient in about every sixth case, and 
had to be exchanged for another method. The uncertainty of 
action combined with the unfavorable results to the life of the 
mother are objections which cannot be denied. With regard to 
the fate of the children, it must be remarked that a considerable 
number of them were born in a cross presentation, altogether a 
larger per centage than with the other methods, a fact easily ex- 
plained by the influence of a concussion (with an upward tenden- 
cy) of the lower uterine segment and its contents. But as it is 
well known that almost all children who are artificially delivered 
before the end of the seventh month are still-born, it will be read- 



22 
# 
ily understood, that everything that has a tendency to produce 
malpositions does actually increase the per centage of still-births. 
These considerations are modified when we examine the history 
of those bases, in which the stream of water, thrown from the 
douche, was directed so as to enter the os uteri. The manoeuvre 
just mentioned has been recommended or executed by Kiwisch 
himself, by Arneth of Vienna, by Simon Thomas, by Trogher, by 
G. T. Elliot, A. K. Gardner, and many others. A glance at the 
results of the operation performed in this manner reveals a re- 
markable difference in the effects of the douche when applied in 
the usual manner. In most instances the result was striking, 
pains arising soon after the first application, while a few cases are 
recorded where death followed upon its administration. One in- 
stance of this kind is reported by Chiari, in which during the applica- 
tion of the douche, the patient was taken with convulsions, cyanosis 
dyspnoea and died soon afterwards. A similar case is reported by 
Dr. Germann (see Monatschriflfur Geburtsk. xii., p. 193), who, after 
thirty-seven unsuccessful applications of the douche in the usual 
manner, introduced the mouthpiece of the chlysopompe into the os 
uteri one inch, and threw about one or one and a half ounces of 
cold water into the cavity of the womb. The patient perceived im. 
mediately afterwards a kind of tension and expansion of her abdo- 
men. A few hours later, she had a most violent chill, and at once 
a series of the most forcible labor pains, of such a character that 
Dr. G. became alarmed for the patient's safety. The child was 
born, and twenty-four hours later the woman was a corpse. 

It appears that the application of the- douche, with the nozzle 
inserted into the mouth of the uterus, is a proceeding in many 
respects similar to that above described as Cohen's method, only 
less certain in its results, and, as it seems, more dangerous. We 
think that every reader of this article will conclude with us that 
the douche, used in the way first recommended by Kiwisch — i. e., 
without introduction of the mouthpiece into the cavity of the 
neck, is a procedure, in the generality of cases, too slow, too un- 
certain, and, as it seems, too dangerous for both mother and child, 
to be relied upon, and it is now quite common to direct the 
stream of the douche into the uterus. But if labor is promptly 
induced in this way, this is mainly due to the water which 
entered by chance into the uterine cavity. It is really only by 
chance that the water passes between the uterine walls and the 



23 

membranes, unless driven in by strong force ; a proceeding too 
dangerous, as we have shown above, to be recommended. But if 
it is our intention to throw a certain quantity of water into the 
uterus, why not choose a method which is better adapted to the 
purpose, far more prompt in its effect, more safe to mother and 
child, easier for the operator, and less troublesome to the patient ? 
We, therefore, propose to abandon the douche entirely, except in 
certain cases hereafter to be named, and substitute for it the in- 
jection of warm water into the cavity of the womb, by means of a 
catheter and a common syringe. I am sure that every one who 
has once tested Dr. Cohen's method, will be struck with the gen- 
tleness and promptness, of its action, and the simplicity of its 
execution. In most instances, only one or two injections were 
required, and the average duration of labor from the time of the 
first injection was two days ; not one instance is known of its fail- 
ure, while the prompt recovery of the mothers in childbed, with 
the exception of those few cases where death resulted from eclamp- 
sia, gives us the best guarantee of the harmlessness of this proced- 
ure. Moreover, the apparatus required consists of such simple 
means, that every country-practitioner, residing in the smallest 
village, is in possession of them ; they consist of an elastic catheter, 
a common enema-syringe, and a few ounces of warm water. The 
performance of this simple operation requires only a sufficient 
knowledge of the female sexual organs in the state of gestation, its 
execution is fully detailed in the history of the cases at the head 
of this article, and the only precaution to be taken is, to inject 
the water not with violence and force, but gently and slowly. 
But we meet, from time to time, with such a disposition of the 
internal sexual organs, that the introduction of a catheter is abso- 
lutely impossible, whether from a firm closure of the os, or from a 
location of the vaginal portion, so that it is out of our reach, in 
an upward or backward direction. Under such circumstances, 
we have to resort to a preparatory treatment in order to change 
the condition of the lower uterine segment, a treatment which in 
many cases may prove sufficient to induce efficient labor pains. 

Of all means which may be chosen for this purpose, the douche 
is no doubt best adapted to our purpose. In acting principally 
upon the lower circumference of the womb, it is apt to soften the 
parts, to open somewhat the os, and to bring the vaginal portion 
more in the direction of the pelvic axis. "We will further remark 



24 

that Cohen's method ought not to be resorted to when induction 
of labor is required in case of uterine haemorrhage, from whatever 
cause it may arise. In such cases, nothing can surpass the caout- 
chouc bladder-plug (Braun's colpeurynter), which, introduced 
empty and filled with ice water, at once controls the bleeding by 
the double action of cold and pressure, and is almost sure to 
induce efficient labor-pains by its mere presence in the vagina. 

ARTICLE II. 

Four Cases of Injection of a Caustic Solution into the Cavity of the 
Womb, illustrative of the Advantages and Dangers connected with 
this Proceeding. By E. Noeggerath. M.D. 

Case 1. — Intractable Hemorrhage; Injection of Iodine ; Cure. — 
Mrs B , of New York, a well formed woman, of dark com- 
plexion, somewhat emaciated and pale, has been suffering from 
uterine haemorrhage for the last twelve months. She was mar- 
ried six years ago, and had one child, a boy five years old. Two 
years ago, her husband died, and left her in charge of an estab- 
lishment for prostitutes. She became pregnant, and not wishing 
to bear her child to the full term, she applied to an irregular 
physician of Brooklyn, with a view of having an abortion per- 
formed. This was effected, by means of introducing a pointed 
instrument into her womb, and a few days after the operation, the 
contents of the uterus were discharged. From this time, she 
flowed freely for about two weeks, when the haemorrhage ceased 
gradually for about ten or twelve days. It returned regularly 
every fourth week, and lasted for about a fortnight. The blood 
she lost was dark and clotted, and its discharge was increased 
when the patient moved about. Latterly, the haemorrhage was 
so violent, that she applied for medical attendance, and notwith- 
standing she had tried several skillful physicians, one after 
another, not the least impression was made upon the quantity of 
blood lost. Finally, I was called in (June, 1858), and found her 
suffering very much from repeated loss of blood, and unable to 
attend to her business. First, I applied such internal remedies as 
I thought proper under the circumstances, recommending at once 
absolute rest in the recumbent position. Alum, tannin, ergot, 
iron, oxyde of silver, were administered in large doses, and 



25 

although every one of these remedies was allowed to have a fair 
trial, the haemorrhage was only arrested for a short time. Exter- 
nal applications were added, cold fomentations, astringent injec- 
tions, but with no better result. In this way, I attended her for 
about three months, without making any actual progress towards 
a radical cure. All that could be ascertained by an examination 
of the parts, was a slight hypertrophy of the whole organ, and the 
very easy passage of the uterine probe, as high as the fundus. 
The latter circumstance, combined with the complete absence of 
pain, served to induce me to try an intra-uterine injection. With 
regard to the cause of the bleeding, I was of opinion that there 
existed small polypoid growths in the cavity of the womb, as rem- 
nants from an incompletely detached serotina at the time of abor- 
tion, or a hypertrophical swelling of the mucous membrane in 
general, owing to imperfect involution after the act of violence 
alluded to. In both instances, an intra-uterine injection was not 
only justified, but demanded. An intra-uterine syringe, with 
long pipe, made of hard-rubber, and of about §ss capacity, was 
filled with tinctura jodi, and the slender mouthpiece introduced 
through a speculum into the cavity of the womb, until it touched 
the fundus uteri. By slowly advancing the piston, I emptied the 
contents into the uterus, which were immediately expelled beneath 
the syringe, and thrown back into the speculum by violent con- 
tractions of the womb. This first injection was made at the time 
when the last haemorrhage had nearly subsided, so that I had be- 
fore me about twelve days till the next menstrual period. Besides 
a sensation of fullness about the bowels, nothing was perceived by 
the patient during or after the injection. She immediately after- 
wards got up and walked about the house. The reaction being 
so very trifling, I asked the patient to call at my office every other 
day, to have the injection repeated. This was regularly done, 
and after every injection, the patient rode and walked down from 
Twenty-sixth Street to Centre, near Broome Street, without 
experiencing the least inconvenience. The iodine was thus em- 
ployed four times before the next menses made their appearance, 
and when they came on, a complete change in their character 
could be remarked. The blood was fluid instead of clotted, con- 
siderably brighter colored than before, and lasting for five days, 
not more copious than is usual in a woman menstruating nor- 
mally. When the period was over, I repeated the injections 
2 



26 

twice a week, in order to consolidate the results already ob- 
tained. The next period was all that could be desired, and I dis- 
charged her as cured. She afterwards left for the country, but 
from occasional reports of her condition, I am aware that she has 
had no recurrence of haemorrhage. 

Case 2, — Uterine hemorrhage, of twenty-three years' standing, 
cured by a single injection of diluted liquor ferri sesquichlorati. — 
Alarming symptoms after the Injection; Slow Recovery. — Mrs. 
G d, of East Seventeenth Street, forty-five years of age, of Ger- 
man parentage, menstruated early in life, and her courses con- 
tinued regular up to the year 1835, when she was married, and 
nine months later, delivered of a healthy child. The confinement 
was as natural as could be desired, so that she was about the 
house beforenine days had elapsed. Although she did aot nurse 
iher baby, her courses did not appear until twelve months after 
delivery, brought on, as it seems, by the use of emmenagogic 
Temedies, and then lasted for half a year without intermission. 
Medical advice was sought, and everything was tried to bring on 
;a more natural periodical discharge. But treatment seemed to 
lhave very little influence, the flux ceasing only ten or twelve days, 
•to return with unchecked violence. This condition lasted for six- 
teen or eighteen years, when the menorrhagic attacks began to 
increase. For the last five or six years, she had very often only 
;a few days of intermission, and this space was filled by an even 
imore troublesome acrid watery discharge. At the beginning of 
1857, new complaints were added, viz., a burning pain in the 
ovarian region, and a sharp pain at the time when she had sexual 
intercourse, which act was always followed by a discharge of 
blood from the genitals. She therefore dragged out a most 
miserable existence, being all the time wet with blood or other 
•discharges ; constantly in pain, weak, nervous, and emaciated, 
without the hope of relief, and altogether a burden to herself and 
family. Under these circumstances, I was called upon to see her, 
and give my advice. I found a person whose aspect was pitiful 
to witness, of an ashy complexion, a mere skeleton, scarcely able 
to move, and even fatigued by a short conversation, but resolved 
to submit to anything that might effect a change in her condition, 
Ibe it at the risk of her life. When I saw her, I was moved with 
-a strong desire to give her all the relief that might be afforded by 
medical science and art, but my hopes with regard to a radical 



27 

cure were very faint, not so much from the reduced state of the 
patient's health, as from the fact that she had been for the last 
few years attended, without deriving much benefit, by Dr. S., a 
physician for whose ability and learning I entertain the highest 
admiration. A digital examination being necessary, was readily 
consented to. The vaginal portion of the uterus rested somewhat 
lower than it ought to be under normal circumstances, was con- 
siderably thicker, but soft, the os tincae patalous, and covered with 
small granulations. By the double touch, the entire organ ap- 
peared to be enlarged, and of a more spherical form than usual, 
painful even upon gentle pressure ; left ovary considerably en- 
larged, and very painful. By examining through the rectum, a 
pretty large section of the posterior surface of the womb could be 
circumscribed, and in this way it was ascertained that a hard, 
flat tumor, of considerable size, was imbedded in the uterine tissue. 
The probe passed easily into the cavity, and could be advanced three 
inches and a half, thus giving a hypertrophy of one inch in length. 
The results thus obtained, together with the patient's account of 
her ailings, induced me to assume that I had to deal with a fibrous 
growth in the uterine tissue, or a simple uterine polypus, protrud- 
ing into its cavity. In order to make sure of the diagnosis, and 
as a preparatory step for treatment, I proceeded to enlarge the 
uterine cavity, by means of compressed sponge tents. 

First, a sponge of small circumference, one inch and a half long, 
was introduced, and left there for about eight hours ; a time suffi- 
cient for its perfect softening and expansion. Immediately after 
its removal, a second sponge was introduced sufficiently long, 
nearly to touch the fundus uteri, and left there over night. I was 
now enabled to pass my forefinger almost its entire length into 
the cavity of the womb, so that I was enabled to examine its 
entire inner surface. No polypus could be detected, the mucous 
membrane seemed to^ be not perfectly smooth, perhaps, owing to 
the influence of the irregular surface of the sponge, which stuck 
very fast to it in every direction, when it was withdrawn. While 
thus examining the womb, there was a feeling as if the posterior 
wall protruded to a great extent, and as if a large hard body was 
situated behind the thickened lining membrane. This examination 
excluded the diagnosis of polypus uteri, verifying that of inter- 
stitial fibroid tumor. I now proceeded to introduce a glass- 
speculum into the vagina, and through it a syringe, which 



28 

contained the liquor ferri sesquichlorati mixed with equal parts of 
water, making altogether about half an ounce. The mouthpiece 
being advanced up to the fundus uteri, its contents were emptied 
into the womb, and almost instantly rejected into the vagina. I 
took care not to remove the speculum as long as a drop of the 
solution came away from the os uteri. The first symptom was a 
burning sensation in the vagina, which was owing to a portion of 
the injected fluid, which came in contact with the vagina, when 
the speculum was withdrawn. The injection was made at eleven 
o'clock, A. M., April 30, 1858. When I saw the patient in the 
evening, she seemed to be much prostrated, always complaining 
of the soreness above mentioned, and a dull pain in the lower part 
of the stomach, which corresponded with the uterus. I ordered 
cooling injections into the vagina, and a few doses of acetate of 
morphium. On the following day, her condition was not much 
changed ; the sore spot less noticed ; pains in the stomach in- 
creased ; sensation of nausea ; continued morphium. Third day ; 
so low that she was scarcely able to move or speak ; pain in 
the uterine region increased by the slightest touch ; abdomen 
slightly swollen ; ordered stimulant drinks, opium with camphor. 
In the evening about the same ; complained of headache and gid- 
diness ; pulse about 130 ; very feeble ; abdominal pains not re- 
markably increased. Fourth day : very much prostrated ; her 
family thinks she cannot live much longer ; pulse scarcely per- 
ceptible ; skin cold ; constant nausea ; no change in local symp- 
toms ; ordered brandy and quinine. Sixth day : feels a little 
stronger ; pulse somewhat stronger ; treatment continued. 
Seventh day : slowly improving ; remarked a few drops of a 
watery discharge from the vagina. With returning irritability, 
the pain around the uterus is more acutely perceived, and I 
therefore had a blister applied above the pubic region, as soon as 
I considered her strong enough to bear all the pain and trouble 
connected with the dressing a blister. Recovery proceeded very 
slowly, and not without one or two alarming relapses, which 
threatened to carry her off. The discharge above mentioned, 
continued for eight weeks, when she had, for the first time, a 
small flux of blood which lasted for five days. It was not before 
ten weeks from the day the injection was made, that she was 
strong enough to leave her bed, and then, only for a few hours at 
a time. One month after the first show, she had another dis- 



charge of blood which continued six days, but did not make an 
unfavorable impression upon the state of her health. At the end 
of August, 1858, she was able to leave her house to be removed 
to the country, where she gained strength considerably, and in a 
comparatively short time. Her menses appeared every fourth 
week regularly, diminishing in quantity on every succeeding turn, 
so that from October last, she professed to have her courses as reg- 
ular, and in that quantity which every healthy woman ought to 
have. 

Case 3. — Injection of a Caustic Solution into the Uterus ; Severe 

Metro-peritonitis ; Recovery. — Mrs. K , of Seventh Avenue, 

called at my office to be treated for fluor albus, of which she had 
complained ever since the birth of her last child, which was now 
about two years old. She had been attended by several physi- 
cians, who prescribed internal remedies and astringent injections ; 
but all to no avail, for as soon as she stopped using the syringe, 
the white discharge came on in undiminished quantity. Latterly, 
her courses had become very scanty, her strength began to give 
away, and she was constantly tormented by a pain in the small of 
her back. Upon examination, I found the vagina covered with a 
copious, thick, semi-transparent fluid, the uterus in its normal posi- 
tion, slightly sensible to the touch, very little hypertrophied, 
mouth somewhat open, its surface not quite smooth, both lips cov- 
ered with red granulations, and bathed in a muco-purulent 
secretion from the cavity of the womb. This was no doubt a fair 
specimen of catarrhus uteri, and a caustic application to the dis- 
eased surface seemed to be the very thing that was required, as 
the only safe means of effecting a permanent cure. I, therefore, 
introduced the mouth-piece of an India-rubber syringe with long 
pipe, containing a few drops of a solution of one part of nitrate of 
silver to four parts of water, into the mouth of the uterus, and 
emptied the contents of the syringe very slowly into the womb. 
Most of the fluid returned immediately, and I am sure that the end 
of the syringe entered not further than one inch into the cervical 
canal. 

When the patient stepped from the lounge she had to sit down 
quickly upon a chair, because of a transient sensation of fainting. 
This was at three o'clock, P. M., and at about six o'clock I was 
called in haste to see her at her residence. I found her very low 
and uneasy, vomiting incessantly, and complaining of pain in her 



30 

head. I learned that a few minutes after leaving my office she 
began to vomit, and continued to vomit to the time of my visit. 
There was besides a dull pain both around the left ovarian and 
the pubic region, which increased on pressure with my hands ; 
still the abdomen was not tense nor swollen ; pulse feeble, about 
one hundred strokes in a minute. I ordered Magendies solution 
dissolved in potio Riveri, and linseed poultices to be applied to 
the painful spot. , She passed a very uncomfortable night, feeling 
as if she was always near fainting, and vomiting as soon as she 
took the least drink. I found her on the following day very low 
and pale, so much that I felt alarmed about her condition, pulse 
one hundred and thirty, feeble, pain in the region of the womb 
increased. Ordered a large blister and powerful doses of opium 
with camphor, small pieces of ice to be taken when she felt 
thirsty. Towards evening she was under the influence of the 
drug and felt somewhat easier. On the third day, the vomiting 
had' almost entirely ceased, but she did not dare to lift up her 
head, fearful of increasing the sensation of giddiness which she 
had experienced from the very first day of her sickness. The 
pain in the lower part of the stomach not increased, pulse falling. 
All the while not the least show of a secretion from the vagina 
was remarked. On the following days her condition was even 
more satisfactory, especially on the sixth day. when a flux of clear, 
bright blood had suddenly made its appearance. The blister was 
now permitted to dry up, and the patient was able to leave her 
bed on the tenth day from the time of the caustic application. 
After this she could not be induced to continue a course of local 
treatment, being impressed with the idea that the first attempt 
had come very near killing her. 

Case 4. — Application of a Solution of Nitrate, of Silver to the inner 

surface of the Womb ; Death on the sixth day. — Mrs. U , of 

Sixth Avenue, a slender woman of light complexion and an irrita- 
ble disposition. When I saw her first (September 1856), I was 
called to attend her for the " whites " and " pains in the small of 
her back." Of her history I learned briefly that she was married 
about seven years ago to a man, who not only neglected her, but 
whom she suspected of having intercourse with prostitutes, from 
the fact of his having contracted a venereal disease, for which she 
could not account in any other way. Upon being questioned, 
she admitted that her disease might have been communicated to 



31 

her by her husband. Although she was not able to trace the exact 
time when she began to suffer ; she had been ill for one and a half or 
two years. The discharge of which she complained was at first very 
little and thick, becoming more profuse, watery, and somewhat 
offensive of late. This circumstance, connected with her growing 
daily thinner and weaker, induced her to seek medical advice, and 
she readily submitted to a thorough examination. The vulva and 
vagina were bathed in a serous, greenish, offensive fluid, and conse- 
quently were red and irritated. Upon examining the uterus with 
the finger, it was found that about two-thirds of the vaginal por- 
tion were gone, and what little remained, the seat of an irregular 
ulceration which extended far into the cavity of the neck. This 
part was laid open to view by means of a speculum. The surface 
thus exposed was of a dirty, grayish color, with irregular, sharp 
cut protuberances, limited by a jagged margin which, towards the 
right side, embraced part of the laquear vaginae. A small particle 
was taken away from this diseased spot for microscopical examina- 
tion. It was afterwards found to consist of nothing but the nat- 
ural elements of the cervical portion, areolar tissue, and fibres of 
organic muscles, all of which were in a state of desintegration, 
representing a granulated appearance, as if interspersed with 
molecular (fatty) corpuscula. 

Diagnosis : ulcus corrodens portionis vaginalis e causa syphi- 
litica. 

Treatment. — We are of opinion that most, if not all, the corro- 
sive ulcers of the vaginal portions are chancres in a phagedenic 
state ; we further believe, that the phagedenic chancre is a 
variety of the soft chancre, thus demanding no general anti-syphil- 
itic but chiefly a local treatment. In this instance, at least, there 
could be no doubt about the nature of the disease, and never had 
any secondary symptoms occurred. On September 15th, the actual 
cautery was applied. An olive-shaped iron was heated white 
and brought in contact with the entire surface as far as it was 
diseased, and even passed into the cavity of the neck for a consid- 
erable distance. The pain experienced during the operation was 
trifling, and the patient rose from the table, where she was placed,, 
and walked to her bed as if nothing had happened. The reaction 
which followed was insignificant, the pulse rising not above nine- 
ty strokes in the minute ; the discharge diminished in quantity 
and quality, being less offensive and of a better color. The 



32 

patient was ordered to take a strong decoction of bark and rich 
food, under which treatment she seemed to recover some strength. 
Ten days after the cauterization she was examined again, and the 
affected portion seemed to be in a fair way towards healing ; in- 
stead of the ragged, pale surface, I found a fresh looking wound, 
partly covered with red granulations. Still some small spots were 
left, exhibiting traces of the old disease. I, therefore, thought it 
necessary to continue cauterization, though on a less active plan. 
Nitrate of silver seemed to be all that could be desired, and I 
dissolved a drachm in an ounce of water to be used for local appli- 
cation. The patient, therefore, was again placed on the table, the 
speculum again introduced, and a small camel-hair brush soaked 
in the solution just mentioned was applied to the ulceration. The 
place which had the most unhealthy aspect was that situated in 
the centre of the os tineas, and thinking that the corrosion might 
have spread far into the neck, I introduced the brush into the 
cervical canal as far as I thought proper, but certainly not more 
than one inch or one and a half. When the patient was brought 
to bed, she remarked that the pain from this application was as 
great, if not worse, than that of the first one. Still she did not 
seem to have any alarming symptoms about her. When I saw her 
on the following day, there was a change in her expression ; her fea- 
tures were not as lively as before ; she felt very weak and com- 
plained of a pain in the lower part of her stomach. This pain 
she had felt coming on gradually ever since the operation, and 
upon closer examination it could be ascertained that its seat was 
in the womb itself; the discharge had entirely ceased, her skin was 
hot but moist, pulse about one hundred and ten in a minute. I 
was at a loss to determine the cause of these symptoms, consider- 
ing it singular that the milder caustic should produce more serious 
symptoms than the stronger one. I ordered her to take the 
extract of hyosciamus in an emulsion of castor-oil, and warm poul- 
tices to be applied to her stomach. The two days following, she 
*was much the same, and, therefore, she continued the hyosciamus 
.•and the poultices. On the fourth day she was rather worse ; 
:abdomen very painful and somewhat swollen ; small doses of 
-opium administered. On the night following, she was very rest- 
less, speaking as if in delirium, constantly grasping her stomach. 
On the fifth day, I found her fully prostrated, with a clammy 
;sweat, a small, fluttering pulse, and only half conscious. I gave 



33 

up all hopes of recovery, but ordered large doses of musk, which 
seemed to revive her, but only for a short time. Towards night 
she sank rapidly, and died about three o'clock, A. M., of the fol- 
lowing day. No post mortem examination allowed. Although 
no autopsy was made in this case, it is clear that the woman died 
from metro-peritonitis, induced by application of a caustic solution 
to the inner surface of the womb. After the first application of 
the heated iron she was in a fair way of recovery, as well with 
regard to the" consideration of the local disease, as to that of her 
general system, she had began to walk around the house, and had 
altogether a brighter look than before. But as soon as the nitrate 
of silver was used, she was suddenly and unexpectedly taken ill, 
with symptoms of metro-peritonitis, from which she ultimately died. 
Although at first I was not inclined to attribute the sudden change 
in the health of the patient to the caustic, I was at last forced to 
consider this application as the only cause of the inflammation of 
the womb and appendages, and I believe that every unprejudiced 
reader will agree in this explanation of the facts. 

From a perusal of the cases reported above, it appears that in 
one of them no reaction whatever followed upon the injection of 
the caustic agent ; two exhibited very alarming symptoms, and one 
resulted in death. The question whether caustic injections into 
womb are connected with dangers or not, seems to be as yet un- 
settled. While some authors reject their use entirely, others seem 
to think light of it, and most of them consider it a safe proceed- 
ing, provided the uterine cavity had been previously enlarged 
artificially. Thus Dr. West, in his recent work on the Diseases 
of Women, remarks : " I say nothing about the use of intra-uterine 
injections in cases of long-standing leucorrhcea, for I have no per- 
sonal experience of their employment, and besides the risk of the 
proceeding has led to their almost universal abandonment." Dr. 
Kiwisch (Klinische Vortrcege, etc.), says the impression following 
upon caustic intra-uterine injections is only momentary and uncon- 
nected with disastrous symptoms, if the fluid injected can easily 
flow back from the cavity. Dr. Scanzoni, when speaking of intra- 
uterine injections (Lehrbuch der Krankheiten der weiblichen Sexualor- 
gane), remarks that he had never remarked any disagreeable 
consequences from caustic injections in those cases where the 
cavity of the womb and the os uteri were large enough to allow 
a free escape of the injected fluid. But from our second case, it 



34 

appears that, although the cavity of the womb had been enlarged 
throughout so as to admit the forefinger to pass inside the womb 
up to the fundus, the reaction was such that the patient's life was 
endangered. The fluid injected in this instance was discharged 
instantly beneath the syringe to its full amount ; very little pain 
was perceived after the injection, and no violent symptoms follow- 
ed after the operation. We must, therefore, exclude the possibili- 
ty that a part of the fluid had entered the abdominal cavity, 
an accident often quoted as the cause of danger connected with 
intra-uterine injections. We are of opinion that the entrance of 
a caustic solution into the peritoneal cavity would give rise to 
instant acute pain on one well-marked spot, and to a rapid devel- 
opment of abdominal meteorism. Nothing of this kind occurred 
in any of our cases, and we are inclined to believe that this event 
is prevented in all cases of caustic injections by the contraction of 
the tubal sphincters excited by the irritating fluid itself. 

We have often had occasion to observe that an irritating injec- 
tion into the womb is instantly followed by a spasmodic contrac- 
tion of its muscular apparatus, driving the fluid out of the os uteri 
with considerable force. This peristaltic motion is no doubt com- 
municated to the muscular layer of the tubes, and as the tendency 
of their action is physiologically directed towards the cavity of 
the womb, it is but natural to suppose that every particle of fluid 
which by chance might have been thrown into the fallopian tubes 
will be immediately rejected into the uterus by the peristaltic 
motion proper to them. But even if this theoretical reasoning 
should leave the least doubt with regard to the non-propagation 
of the fluid through the tubes, we will refer to the fourth case, 
the one which resulted in death. In this instance, the caustic 
solution was brought in contact with the uterine cavity by means 
of a small brush, and was not injected. The quantity of liquid 
thus applied could not be more than one large drop, and the re- 
motest point touched by the brush was about one inch and a half 
distant from the os tineas. But we have often remarked, that a 
strong solution of nitrate of silver is apt to spread considerably 
in the neighborhood of the spot touched with the brush. This 
accident must have happened in the case just mentioned ; the 
fluid proceeded, we suppose, from the cavity of the neck into that 
of the womb, through the sphincter internus, which, paralized as 
it was by a uterine disease of long standing, offered not the least 



36 

resistance to its progress, and by following the laws of gravitation 
it slowly advanced into the uterus, which was slightly retroverted. 
Also in the third case only a few drops were slowly injected into 
the cavity of the neck, and still thi$ was enough to kindle a metri- 
tis, accompanied by such a fearful depression of the system, that 
recovery seemed doubtful. 

The conclusions drawn from these considerations seem to show 
that the dangers connected with intra-uterine injections are not so 
much derived from a passage of the fluid into the abdominal cav- 
ity, as from the direct influence of the caustic agent upon the 
uterus itself. In those cases where the milder caustics are 
applied, or where the organ has only a limited degree of suscepti- 
bility, the injection is followed by a more or less severe endome- 
tritis, which generally terminates by resolution. But under circum- 
stances similar to those mentioned in the history of the cases 
reported, the inflammation seems to proceed to the deeper layers, 
the areolar, muscular tissue, and lastly to the peritoneal mem- 
brane lining the body of the uterus, thus terminating in the most 
disastrous form of metro-peritonitis. 

From this it would appear that we ought to abstain entirely 
from the use of caustic injections into the cavity of the womb. 
For if it is true that they are at times followed by dangerous and 
even fatal consequences, they must be considered as means inade- 
quate to the evils which they are intended to relieve. I mean to 
say that a complaint which is not endangering in a direct way the 
sufferer's life, ought not to be attacked with a remedy that might 
possibly remove the disease and the patient at once. To this class 
of morbid alterations belong hypertrophy, ulceration, abnormal 
secretion, and fungoid excrescenses of the uterine mucous mem- 
brane, conditions which have been often treated with caustic 
solutions. From this consideration, the treatment of violent 
hasmorrhages is naturally excluded ; with regard to them, we must 
act after the principle : aux grands maux les grands remedes. 

In coming to this conclusion, I am far from advising against 
the use of caustics in general. All I want to impress upon my 
readers is the necessity of being cautious in their application, 
more cautious I mean than some of our obstetric specialists. There 
seems to exist a certain climax in the different remedies them- 
selves, some of them, although very effectual, are comparatively 
innocuous, while others are almost always followed by violent 



36 

reaction. Among the former we count the tincture of iodine, and 
some of the organic acids, such as tannin and benzoe, among the 
latter, the solutions of silver and mercury as well as the stronger 
mineral acids. The remedy which most happily combines a high 
degree of innocuity and of efficiency is the tincture of iodine. I 
have had frequent occasions to inject it into the cavity of the 
womb, and as yet I have never remarked the least untoward 
symptom from its application. The use of a strong solution of 
nitrate of silver is almost always followed by a destruction of 
part or the whole of the mucous membrane, an incident which no 
doubt is at times required and intended for effectual treatment, 
and really in many instances this is perfected without any injury 
to the patient's health. It, indeed, seems that a solution which in 
one instance is very well born, does produce the most alarming 
symptoms in another person. In this the uterus resembles the 
urethra of the male, which at times can bear manipulation with 
impunity, while again a single cautious application of the catheter 
may prove fatal. We should, therefore, ascertain the irritability 
of the womb before we attempt to apply one of the stronger caus- 
tics to its inner surface. This can be readily done by throwing a 
quantity of common water into the uterus, this test to be followed 
by a series of weaker and stronger irritating injections. A few 
trials of this kind will soon enable us to learn to what degree we 
are allowed to saturate the solution. Another advantage of these 
graduated injections is the fact of their diminishing the uterine 
irritability, thus preparing the womb for the reception of stronger 
solutions, in case they should be demanded. 



ARTICLE III. 

Remarks an the Employment of Pessaries ; with the description of a 
New Instrument.* By E. Noeggerath, M.D. 

The more intractable a disease has proved to the treatment, the 
greater is the number of so-called infallible remedies proposed for 
it. This is true of prolapsus uteri. Every year, almost from the 
days of Hippocrates, has enriched the number of uterine instru- 

* Tliis article is reprinted with additions from the New York Journal of Medicine for 
November, 1858. 

V 



37 

ments for the cure of falling of the womb, and still the mystery- 
seems to be undissolved. This is partially owing to the fact, that 
till now, no instrument has been constructed that satisfies prac- 
titioners in general, partially to the inventing-mania of some of 
our professional brethren. 

There are two classes of physicians, one of which being dis- 
gusted with the host of mechanical appliances, now lauded, now 
rejected, has almost entirely abandonded the application of pes- 
saries ; while the other treats the slightest deviation with a 
mechanical support. Though the latter do more than the former, 
neither of them proceed upon the correct principle. 

As to the comparative value of the operation for prolapsus, the 
question is not yet settled. When we attempt a final solution of 
the question, whether the average number of subjects operated 
upon are permanently benefited by it or not, we are overwhelmed 
daily with the most contradictory reports of its value. More- 
over, the greatest number of practitioners are called upon to treat 
cases, not in the hospital, but private patients, who claim a right 
to dispose of themselves just as they choose. And most of them 
are alarmed at the very sight of a bistoury. 

And still there are physicians, some of the highest standing, 
who try to avoid the use of a pessary by treating cases of prolap- 
sus, on the so-called radical plan, i. e., by removing the original 
disease, chronic metritis, hypertrophy of the womb, etc., applying 
afterwards astringent injections and suppositories, while the 
patients are laid up for two or six months, to be discharged with 
an abdominal supporter I The great objection to this plan is the 
fact, that it is crowned with success only in an exceedingly small 
number of cases, while its employment is perfectly out of the ques- 
tion in the large majority of cases, because that class of society 
among which prolapsus is commonly found, has neither time 
nor means to resort to it. It is the working portion of the sex 
which suffer with this complaint, and they want a prompt and 
cheap remedy. 

In regard to abdominal supporters (Annan, Hull, Hamilton, 
Giehrl) I consider them as excellent adjuvants in the treatment of 
prolapsus, but the relief derived from them is far less than that 
offered by a well-adapted pessary. 

The only operation which is always followed by great relief, is 
the amputation of the cervix, in cases where the prolapsus is 



38 

owing to hypertrophy of the lower section of the womb. Dr. C. 
Mayer, of Berlin, the well-known obstetrician, has resorted to it 
with the fullest satisfaction in a great number of cases. 

In recommending the use of pessaries in the treatment of pro- 
lapsus uteri, I am far from resorting to it in every-day practice, viz., 
that of diagnosticating prolapsus uteri, and prescribing a pessary 
at once. Nay, there are cases which do not justify instrumental 
treatment at all, while almost every single case demands a 
preparatory treatment before a pessary can be applied. The 
necessity of a careful examination, and a full consideration of the 
complication present cannot be urged too strongly. The neglect 
of this principle is the common source of failure in the treatment 
of prolapsus. For the same reason, no physician should prescribe 
a pessary on the sole assertion of the patient herself, that she 
suffers from falling of the womb. I have frequently met with 
patients, who believed themselves to be subject to this complaint, 
who, upon examination, were found to have metritis or mal- 
positions and flexions of the womb. It is obvious, that a pessary 
in this class of cases, would be injurious instead of beneficial. 

The patient must be examined as well in an erect as in a hori- 
zontal position, as it often happens, that a prolapsus disappears 
entirely when the patient is lying on her back. After the pres- 
ence of prolapsus has been ascertained in this way, the patient 
must be subjected to a thorough examination, while in a horizontal 
position. It is best to begin with the palpation of the abdomen, 
in order to get a knowledge of abnormities in the supra-pelvic and 
pelvic cavities. Hereafter the prolapsed portions themselves must 
be inspected, and the state of the anterior and posterior wall, and 
that of the womb itself, have to be taken into consideration. 

Moreover, the color and condition of the respective mucous 
membranes have to be taken into consideration, as well as the 
presence of ulcerations, their different character, their seat in the 
cervical canal, near the orifice, or on the walls of the vagina. 
Hereafter the prolapsed portions have to be touched all around 
with the fingers, in order to ascertain their condition, and the 
possibility of full or partial reduction. In order to get a full view 
of the position of the uterus, it is well to introduce one or two 
fingers into that portion of the vagina which is inside of the pel- 
vis. By examining through the rectum, we may ascertain how 
far it is involved in the prolapsus. Hereafter the situation and 



39 

size of the womb has to be ascertained with the probe, and that of 
the bladder with the catheter. After this the parts must be 
pushed upwards, in order to examine the sexual organs inside of 
the pelvis and the pelvis itself. In those cases, where the neck of 
the uterus is not in sight, it has to be explored with the speculum. 
The different forms which a prolapsus may represent, are as 
follows : 1. One of the walls of the vagina may prolapse, without 
participation of the womb, viz. : 

(a) Prolapsus of the anterior wall of the vagina. 

(b) Prolapsus of the posterior wall. These cases are generally 
recorded under the name of cystocele and rectocele vaginalis. 

2. Prolapsus of one or both vaginal walls, with partial prolap- 
sus of the womb. 

(a) Prolapsus of the anter-wall of the vagina and partial pro- 
lapsus of the womb. 

(b) Prolapsus of the posterior wall of the vagina and partial 
prolapsus of the womb. 

(c) Prolapsus of both walls of the vagina and partial prolapsus 
of the womb. 

The cases of prolapsus of the anterior wall and the uterus are 
very often connected with retroversion and flexions of the womb. 
The body of the womb is generally turned somewhat backwards, 
pressing upon the os sacrum and rectum. These cases, therefore, 
are very often complicated with very troublesome constipations of 
the bowels. 

3. Prolapsus of both vaginal walls and complete prolapsus of 
the womb. This variety is the most commonly met with, because 
women affected with the disease very often do not apply for medi- 
cal advice until twenty or even forty year3 have passed since its 
first start. 

4. Prolapsus of the uterus. This is of very rare occurrence. 
The inferior portion of the womb, generally hypertrophied in a 
great measure, protrudes between the labia majora as a thin cone, 
which sometimes attains the length of three or four inches. As its 
lower end is rounded off, and perforated by the orifice, it resem- 
bles the penis of the male. 

In most cases of prolapsus the lining membrane is the seat of 
superficial or deeper ulceration. The ulcerations coincident with 
prolapsus must be divided into two different classes, viz., those 
which are the consequences of an idiopathic uterine disease, and 



40 

those which are the result of mechanical irritations. This distinc- 
tion is important with regard to treatment. The ulcerations from a 
mechanical cause are limited by irregular, sharp, callous edges, 
and their base is discolored with a brownish hue, yielding a dirty, 
thin, often very offensive secretion. The ulcerations from chronic 
metritis are of a more inflammatory character, inclined to bleeding, 
spreading rapidly on the slightest occasion, and very obstinate to 
treatment, unless the metritis has been subdued beforehand. 

Other complications very often connected with prolapsus are 
retroflexion retroversio, and anteflexio. Every complete prolapsus 
uteri is followed by hypertrophy of the organ, which attains in 
most cases the longitudinal axis, while at times the womb is con- 
siderably increased in thickness. In the first instances, the probe 
may be advanced into its cavity as far as five or seven inches. In 
other cases the cervical portion alone or one of the lips only are 
hypertrophied. 

In consequence of the displacement of the bladder, always present 
in cases prolapsus of the anterir wall of the vagina, the urethra is 
often covered with fungous vegetations, which at times attain the 
length of half an inch in diameter. Hernia recti and prolapsus ani 
are of comparatively rare occurrence, while ?-upture of the perineum 
is not seldom. These and other complications have to be removed, 
as far as possible, before the application of a pessary can be 
thought of. The treatment of some is very tedious, and demands 
a good deal of patience from the attending physician and the 
woman herself. 

Chronic metritis, hyperemia and 'painfulness of the prolapsed 
parts must be treated with leeches, sacrifications, anodynes, resor- 
bents, etc. The ulcerations have to be cured thoroughly before 
a permanent retention of the womb can be thought of. It is per- 
fectly contradictory to experience, that the reposition of the parts 
into the vagina is sufficient for the cure of these ulcerations, an 
opinion cherished by some of our very first obstetric physicians. 
The only complication which requires no treatment before the 
application of a pessary is simple hypertrophy of the womb. 

The most efficient remedies for treating these ulcerations are 
nitrate of silver, acideum pyrolignosum, scarifications, removal 
with the knife of the callous edges, fomentations with lead-water, 
slight cathartics. 

The ulcerations of the vaginal walls are of a very intractable 



41 

nature ; they are never benefited by the application of caustics, 
Buch as nitrate of silver ; scarifications repeated every third or 
fourth day, and the applications of acid — pyrolignosum answer 
much better. They often require twelve or eighteen months' 
treatment before a sufficiently firm scar has been attained. The 
ulcerations seated in or near the cervical canal must be healed up 
(at least as far as they spread over the lips) before a pessary can 
be introduced, while the treatment of the intra-cervical ulcera- 
tions may be continued afterwards with the speculum. It must 
never be forgotten, that all ulcerations which are touched by the 
pessary will increase and make the use of an instrument impossi- 
ble. Only in those exceptional cases, where the ulcerations resist 
the most rational and persevering treatment, they may be covered 
with a piece of soft and dry lint, and a pessary introduced after- 
wards, and treatment continued intra-vaginam. In those cases 
where bodily rest can be resorted to, it is of great value for the 
cure bf ulcerations ; at any rate, in treating these affections, the 
greatest cleanliness must be observed, the parts must be thorough- 
ly sponged after going to stool, and they must be covered always 
with a clean piece of dry linen. 

The use of a pessary seems to be connected with the greatest dif- 
ficulty in those patients where prolapsus is complicated with both 
hypertrophy and flexion of the womb. 

In the very first days of its application violent back-aohe. a 
sensation of bearing-down and prolapsus of one of the vaginal 
walls make their appearance. When examined, the body of the 
retroflected uterus is found very painful, and ulcerations appear 
on different places. 

In these cases it is a good plan to elevate the retroflected 
womb by the uterine sound, thus fixing it towards the promontory. 
Then a pessary may be introduced and absolute rest recommended 
for some time. If this is not sufficient, the only means left, is to 
introduce a soft sponge behind the cervical neck, which, in many 
cases, does retain the prolapsed womb in its position. The sponge 
has to be removed, cleansed, and reintroduced daily for some 
weeks before another application of a pessary may be tried, which 
at first must be applied in connection with the sponge. By a 
strict and indefatigable adherence to these rules, a pessary is 
finally endured without any inconvenience. 

After a full consideration and treatment of the different com- 
3 



42 

plications, it is of the* greatest importance to choose the right 
kind of instrument. 

The requisites of a good instrument are as follows : 1. Itmu st 
retain the womb in or near its natural position. 2. It must 
neither irritate the womb nor the vagina. 3. It must not inter- 
fere with the patient's moving round, sitting, or excretion of 
urine and faeces. 4. It must be composed of a substance, which 
resists the corrosive influence of the secretions from the genitals. 
5. It must be constructed so as to be easily introduced, removed 
and cleaned by the patient herself. 6. It must be as cheap as 
possible. 

The different pessaries may be divided into two sections, viz., 
those which support the womb directly, and those which support 
it indirectly, by elevating the vagina. Until late years, only the 
former class was exclusively applied, as this idea most naturally 
suggested itself at first sight. They are divided again into stalked 
and unstalked. Both are intended to give a direct support to the 
fallen uterus. Later researches seem to show that the chief and 
most natural support of the uterus was presented by the vagina, 
and in this view surgical operations as well as instruments were 
invented, and, as it seems, successfully applied for the cure of 
prolapsus. 

The first man who clearly followed this indication in construct- 
ing his pessary, was Prof. Kilian, in 1846, and he called it 
elytromochlion — i. e., vaginal supporter. 

His instrument consisted of a thin, 
steel spring, four inches long, the points 
of which ended in wooden buttons, and 
the whole of it was covered with a 
thin layer of india-rubber. In introduc- 
ing the instrument, the ends of it are 
approximated to each other as much as 
is required for its easy introduction 
into the vagina. 

Fig. 1. ° 

In applying it, it must be elevated in the direction of the lateral 
diameter of the vagina, while its convex portion is directed 
towards the anterior walls of the pelvis. The instrument thus 
bent is gently pushed upwards, so that its points take a position 
to the right and left side of the uterine neck, as high up as possi- 
ble in the laquear vaginae. 




43 



Although the instrument has been abandoned by the profession, 
owing to the fact that very few women can bear the pressure 
which it necessarily must exert, in order to sustain itself in the 
vagina, the elytromochlion of Kilian has been applied in some 
cases successfully, thus proving that the theory of its construction 
was based upon sound principles. 

In 1853, Dr. Zwank, of Hamburg, published the description of 
his new hysterophor. It consists of two ovoid thin pieces of metal, 
covered with india-rubber, or of wood, connected on one end by 
a joint. In the neighborhood of this joint, on the external surface 
of the wings, is a metallic pin, on each side two inches long, which 
can be screwed together at the lower end. 





Fig. 2. Fig. 3. 

In applying the instrument, the wings are approached as much 
as possible (fig. 2), and introduced so that its convex portion is 
turned towards the os sacrum, and pushed upwards, as high as 
possible, towards the anterior portion of the laquear vaginae, in 
front of the neck of the uterus. Afterwards the lower ends of the 
metallic handles are compressed, and fastened by the screw 
(fig. 3). In this position the instrument is retained by itself! 

About the same time, Dr. Schilling, of,' Munich, invented! eyuite 
a similar instrument to that of Zwank ; the only difference being, 
that the movement of the wings is effected, and can be regulated, 
by the screw at its lower end. The purpose of both instruments- 
is, to gently expand the lateral portions, and sustain the superior 
wall of the vagina, thus preventing its inversion, and conse- 
quently, the falling of the womb. 

Dr. Zwank's instrument was received enthusiastically by the 



44 

profession in Germany. Such men as C. Mayer, Chiari, Braun, 
Scanzoni, Breslau, etc., thought it of sufficient importance, to pub- 
lish their observations in favor of this instrument, and at the 
present time it has actually supplanted all of its kind. 

What is the reason of this ? Is it because the profession seized 
upon the instrument, because it was a new invention ? Is it be- 
cause an instrument was wanted? or has it fulfilled what it 
claimed to do ? 

The question which we propose to consider, is whether this in- 
strument has any advantage over others hitherto applied for the 
same purpese. It certainly has ; because, 1. It is lighter. 2. It 
touches only a comparatively small circumference of the vagina, 
and scarcely any portion of the womb ; thus preventing irritation 
and ulceration of the vagina, incarceration of the uterus, fluor 
albus, uneasy feelings. 3. It can be easily introduced and re- 
moved, easily brought to its proper place, easily cleaned by the 
patient herself. This is a combination of advantages, sought for 
in vain among the host of previously-invented pessaries. On the 
other hand, the hysterophors of Zwank and Schilling have some 
disadvantages, owing to the substance of which they are com- 
posed. The greatest number of them, as now in use, are covered 
wity a coat of vulcanized india-rubber. The discharges of the 
vagina destroy it in a very short time. After this has been done, 
the metallic portions begin to rust and decay, thus irritating the 
vulva ; the furrows of the screw at the lower end of the instru- 
ment begin to crust, or the screw, if turned too firmly, cannot be 
untwisted. Some patients have little dexterity, and do not know 
how to manage the screw at all. An illustration of these facts 1 
am seeing daily, in the case of a lady belonging to the first class 
of society. She is the widow of a well-known physician of this 
city, and has suffered from pro! aosus uteri ever since her first con- 
finement, many years ago. The most thorough examination is 
unable to detect anything abnormal about her genital organs, ex- 
cept prolapsus uteri. She has been under the very best treatment 
cff general practitioners and uterine specialists. Everything has 
been resorted to, to effect a radical cure, and all kinds of pes- 
saries employed, but in vain. At length, one of Zwank's pes- 
saries was suggested. She has worn it now for a year, and is 
perfectly satisfied ; the only drawback being the loss of the india- 
ridiber coating, and .the rusting of the metallic Skeleton. 



45 

In order to avoid these inconveniences, Dr. Eulenburg, of 
Coblenz, modified Dr. Zwank's pessary, and described his instru- 
ment in a short thesis, in 1857. It is made entirely of boxwood, 
and its wings are a little differently shaped, viz. : they are slightly 
curved downwards at both ends, so that the lower side forms a 
concave surface. In consequence of this shape, the lateral 
branches closely adapt themselves to the inner surface of the 
ramus descendens ossium pubis ; thus presenting a kind of hook, 
which gives a strong hold to the instrument when in the vagina. 
Both wings move in the centre part by two joints, thus leaving a 
hole in the middle, through which the secretions of the vagina are 
allowed to escape. Instead of the screw, Dr. Eulenburg perfected 
the opening and shutting of the wings, by means of an elastic 
india-rubber ring, which runs in a channel around the body of the 
hysterophor, immediately below the two joints. 




Fig. 4. 



Fig. 5. 



By this contrivance, the introduction of the instrument is 
greatly simplified, and as it shuts on its own account, by the elas- 
ticity of the india-rubber ring, its application becomes very easy, 
thus requiring not the least ingenuity upon the patient's part 
(see figs. 4 and 5). As every particle of metal is avoided (except 
the small pin, running through the joint), and as the boxwood re- 
sists more than any other substance the corrosive influence of the 
vaginal discharges, it is lighter, will keep longer, and will cause 
less irritation than the other instruments. 

The author found four different sizes, fitting to the greatest 
number of cases, viz. : for the measure from side to side, 2|"„ 
3", 3£" and 3£", and correspondingly the largest anteroposterior- 



46 

diameter of every wing, 1" 3"', for the two largest sizes, and for 
the following, 1" 4'" and 1" 5'".* 

The first application of the instrument ought to be performed 
by the physician himself, who has to choose the size required for 
every case. His judgment will be conducted by the sensation of 
the patient, after walking to and fro for awhile, and more so by 
the way in which the india-rubber ring contracts. If the extra- 
vaginal portion is not shut entirely, the instrument is too large, and 
lias to be removed ; if it shuts too quick, a larger one must be 
chosen. The following duties devolve upon the patient herself, 
viz., removing and cleaning it at bed-time, and readjusting it 
before getting up in the morning. This is performed by seizing 
the buttons at the lower end, and while separating them from each 
other, as much as possible, the other end of the instrument is 
to be gently introduced into the vagina till it cannot go any fur- 
ther ; and (when left alone) now it shuts on its own account. The 
same way is followed in its extraction. Before its introduc- 
tion, it ought to be well oiled. In order to render this pessary 
even more harmless, it is advisable to cover its branches with a 
kind of glove, made of soft deer-skin, which coat may be moistened 
with cod-liver oil before every application. 

Of great importance is the breadth and direction of the pubic 
arch, because this is the chief guide for the selection of a pessary. 
It can be ascertained by introducing the second and third fin- 
ger behind the arcus and expand both fingers till each of them 
touches one side of the arcus. The distance of the fingers thus 
obtained may guide our judgment in the choice of an instrument. 
As a general rule it may be stated, that a comparatively small 
instrument ought to be tried first, because it very often happens, 
that even the most extensive prolapsus is benefited by small 
instruments. 

After the instrument has been closed, the patient must be ques- 
tioned as to what her sensations are. If the instrument was too 
large, a singular kind of smarting is perceived and considerable 



* The instrument has been modified in the construction of the joint after my sug- 
gestion, so that the pessary can be easily taken in two lateral pieces, thus allowing 
a more thorough cleansing, while even the small metallic pin of Dr. E.'s pessary is 
avoided. Sold by G. Tiemann & Co., No. 63 Chatham Street, New York. "Lately 
Mr. Russel has modified for Dr. Savage, of London, Mr. Zwank's instrument, in Buch 
a way. that the metallic screw is avoided, and from a sketch of it in the Medical 
limes and Gazette, we should think that the modification is a very happy one. 



47 

uneasiness expressed. It is a good plan to have the patient walk 
around, in order to ascertain if the prolapsus will be perfectly 
retained by the instrument. 

Even in cases where the perineum has been ruptured, our instru- 
ment has been used with perfect success ; the only precaution to be 
taken, is the choice of a broad pessary. 

On the second day after the application of the instrument, the 
patient must be seen again by her attending physician, because at 
this time generally certain symptoms occur, which originate from 
the presence of a foreign body in the vagina, and which prove, if 
they are very intense, that the instrument is too large. 

The symptoms alluded to, are a chilly sensation, heat, headache, 
trembling, nausea, want of appetite, obstinate constipation. The 
instrument must be removed, and the vagina must be examined 
with the speculum, to see if a portion of it is inflamed or ulcer- 
ated, a condition always met with, if the instrument chosen was 
too large. After xhe third day is over, chills and heat are very 
trifling, and disappear entirely some time afterwards. 

If the instrument is borne after some days with no discomfort 
at all, the patient must be taught how to use it, and must repeat 
the manoeuvre of adjusting and removing it several times in the 
presence of the physician. 

At the time of the monthly courses, the patient had better have 
the instrument removed, provided she can keep quiet. At times 
it happens, that a portion of the anterior wall of the vagina falls 
beneath the pessary. In this case, a broader instrument must be 
chosen, or a small piece of plugged linen must be placed in the 
midst of the instrument, corresponding with the prolapsed portion , 
which is easily retained by this contrivance. 

In recommending these instruments, and especially the latter 
one, to the consideration of the profession, I am sustained by the 
experience of our European brethren, who have used them with 
such general satisfaction, that scarcely any other form is now in 
use. Lately Dr. A. Mayer, of Berlin, has published a paper on 
the use of Zwank's pessary, wherein he reports to have success- 
fully applied it in two hundred and thirty cases. For my own 
part, I avoid the use of pessaries as much as possible. But I have 
had under my care a number of cases, in which a pessary was the 
only means justifiable. I have tried a great variety of them, and 
have now come to the conclusion that Zwank's (or Eulenburg's) 



48 

hysterophor answers better the requisites of a good pessary than 
any other. 

I, therefore, ask practitioners to give it a fair trial. I do not 
mean to buy a hysterophor, and sell it to the next woman with 
prolapsus uteri, but after carefully selecting the case, in which 
nothing but a good pessary will give sufficient satisfaction, let the 
different sizes be tested, until the proper instrument is found. 

ARTICLE IY. 

A Contribution, to the Pathogenesis of Uterine Polypi. By E. 

NOEGGERATH, M.D. 

Mrs. Fischer, of New York, apparently a healthy woman, was 
delivered on the 12th of July, 1858, of a strong, living child, after 
a short and easy labor. She was attended by Dr. Rupprecht, to 
whom I am indebted for the history of this case. Soon after the 
child was born, the placenta was found lying in the vagina, near 
the os externum, and removed without the least difficulty. The 
doctor left in about an hour, but was scarcely at home, when he 
was summoned back to the patient in haste, as the woman was 
" swimming in blood." On his arrival, the haemorrhage had 
already ceased spontaneously, the uterus was found well con- 
tracted, and as nothing seemed to indicate any farther appre- 
hension, the patient was quieted, and stimulating drinks ordered 
to be taken. 

During the following days everything proceeded as well as 
could be expected, secretion of milk and lochial discharge in the 
best condition. At about the ninth day after this, the woman re- 
marked another show of blood, which, however, did not seem to 
be serious enough, to call for actual treatment. A strengthening 
diet, combined with the use of tonics, was recommended, and suc- 
cessfully so, as the discharge diminished, while the patient was 
gaining strength. But this condition did not last very long. 
After a lapse of four days, the blood began to flow anew, and in 
such quantities, that it occasioned serious apprehensions. Under 
these circumstances, Dr. Rupprecht insisted upon a thorough ex- 
amination of the parts involved ; on passing his forefinger into 
the vagina, he detected a large tumor filling the entire space of 
the vagina. This body was of the size of a large hen's egg, per- 



49 

fectly smooth, round, and somewhat flattened on its upper ex- 
tremity, where it was firmly attached to the anterior lip of the 
vaginal portion. This attachment was so firm, that by moving 
the tumor, from right to left, the entire uterus was displaced side- 
ways.. This examination, although performed with the greatest 
care, produced an alarming increase of the haemorrhage. From 
these symptoms, and his examination together, Dr. Rupprecht 
concluded that she was suffering from a polypus of the womb, 
which ought to be removed as early as possible. He accordingly 
prepared to perform the operation, with the assistance of Dr. 
Michaelis, who agreed with Dr. R.'s diagnosis. But the patient 
insisted upon calling in a third physician. Consequently, Dr. 

P met them, and after examination, declared that the case 

was not one of polypus, but inversio uteri. But as neither Dr. 
Rupprecht nor Dr. Michaelis coincided in this opinion, it was de- 
cided to have Dr. Krackowizer's opinion. The latter gentleman 
began his examination with the forefinger, to which he added the 
third finger, in order to circumscribe more easily the entire sur- 
face of the protruding mass. He found that the lower surface of 
both uterine lips was imbedded in the tumor, and he confirmed in 
every other respect, the results of Dr. Rupprechts examination, as 
given above. In the process of examination, Dr. Krackowizer 
directed his fingers so that they held the vaginal portion be- 
tween them ; and when pressing downwards upon the polypus, he 
had the sensation as if something yielded, which induced him to 
increase the pressure, when suddenly the polypus separated from 
its place of attachment, and was easily extracted from the vagina, 
after which the haemorrhage ceased entirely. 

The polypus was removed on the morning of July 25th, and I 
had occasion to examine it on the same day at three o'clock, P. M. 
It was of a spherical form, its longest diameter being about 2\". 
The entire mass was perfectly smooth, and seemed to be lined 
with a proper membrane. The continuity of this membrane was 
broken at the lowest section of the tumor, and on this portion a 
cleft \" long could be observed, which, running from right 
to left, partly disclosed a fibrous, bluish-white heterogeneous 
substance, which, upon closer examination, proved to be an ob- 
literated blood-vessel. The upper aspect of the tumor, instead of 
being smooth like the rest, showed an irregular, rugged surface 
in its middle portion, of about the size of a fifty cent piece. This 



50 

place looked very much like a fresh granulating ulcer, and was 
undoubtedly the seat of adhesion with the uterus. The entire 
mass was solid, and as hard as the normal uterine tissue. Upon 
dividing its deeper portions with the knife, it offered the color 
and consistency of muscular tissue, now and then interspersed 
with lighter tendinous stripes, which ran in every direction. 
We were altogether at a loss what to make out of this tumor, and 
it was left to the microscope to throw sufficient light upon its 
true nature. For when a small section of it was examined, it be- 
came evident, that the whole mass consisted chiefly of shriveled 
tufts belonging to the chorion. And, consequently, the polypus 
before us, was nothing but part of the placenta. "We must add, 
that the tumor was entirely free from any offensive smell. 

From the history of the case, it appeared not only that the 
physician removed the afterbirth without the least obstacle, but 
that it had already descended into the vagina, when its removal 
was attempted. This circumstance, as well as the regularity of 
its shape, induces us to believe, that the tumor in question, was a 
so-called placenta-succenturiata. The time when this placenta 
was detached from the cavity of the womb, must have been imme- 
diately (one hour) after delivery ; it was preceded by a sudden 
and violent haemorrhage, which ceased spontaneously. This symp- 
tom is always observed in cases where portions of the placenta 
or the membranes are retained in the womb, as every accoucheur 
will readily admit. After the mass had left the uterus, no 
haemorrhage ensued until the ninth day. This was the time 
when reunion with the uterus was completed, and the oozing of 
blood, which, set in now, was caused by the same circumstance 
that causes the bleeding in cases of genuine uterine polypi. 
That this adhesion with the womb was not a mere agglutination, 
but an organic union, is proven : 1. By the fresh condition of 
the corpus delicti. It is well known that no substance under- 
goes putrifaction more readily than the detached placenta, 
especially when deposited in the vagina, where it is in free con- 
tact with the atmosphere and the vaginal discharges. 2. By 
the smoothness of its surface and the rounded shape, an attribute 
proper to living organic tissues. 3. By the appearance of the 
granulated part on its upper plane, which might be compared 
with the raw surface of a tumor just removed by enucleation or 
torsion. 4. By the bleeding following upon its being touched 
with the finger. 



We therefore conclude, that this is an instance of migration of 
a placenta-succenturiata from the cavity of the womb, and re- 
attachment to its vaginal portion, with a tendency to be trans- 
formed into a uterine polypus. If the case had not been so 
promptly attended as it was by Dr. Rupprecht, if only its chief 
symptom, the bleeding, had been treated, as it is done too often 
under similar circumstances, the patient would have at the present 
day a polypus uteri, which, detached, perhaps, after a lapse of 
years, and removed with the knife, would not excite the least 
interest, the minute circumstances connected with the history of 
the case being lost and forgotten. Although not a few cases are 
recorded in our literature of placentas remaining in organic union 
with the uterus, we think that the observation just laid before our 
readers, is unique in its way, and may perhaps serve to throw 
some light upon the pathogenesis of uterine polypi. 



ARTICLE V. 

Invagination of the Colon Descendens in an Infant, with Repeated 
Hemorrhages in the Colon Transversum* By A. Jacobi, M.D. 

Invagination of the intestines, from a merely anatomical point 
of view, is not a rare occurrence. Before and in the moment of 
death, the paralysis of the muscular tissue of the intestines pro- 
gressing by degrees and sometimes unproportionally, invaginations 
of the jejunum and ileum are very frequent ; indeed, so much so, 
as to be a very common result of a great many post-mortem exam- 
inations. The same alteration is not of the same frequency in 
the living, but wherever it occurs, it is generally known to be a 
dangerous disease. It occurs, in almost all the cases, in the 
jejunum and ileum, the intestina crassa being as it were exempt. 
The reason why this is so, is : 1st, the vast development and con- 
siderable strength of the muscular fibres of the intestina crassa ; 
and 2d, their firm adhesion in the fossa iliaca. Now, in very 
young children, neither of these things are found ; in them the 
muscular tissue of the colon is not very much developed, nor are 
there strong adhesions in the fossa iliaca. Therefore it is only 
natural, that there should be, in infants, cases of invagination of 

* Jiew York Journal of Medicine, May, 1858. 



52 

the intestina crassa, so very unusual in older children or in adults. 
Nevertheless, there are not many observations of such cases, and 
the literature of the subject is very poor, so much so, that a number 
of even the best manuals on diseases of children do not mention it. 
For this reason the profession is under the greatest obligation to 
Rilliet, who collected more than a dozen of well-authenticated 
cases, and described the disease in so masterly a manner as only 
Rilliet and Barthez are able to do. And for the same reason I 
think it important to relate the following case of invagination of 
the colon descendens, with its peculiar complication with enter- 
orrhagia, in order to establish if possible the exact diagnosis of 
this dangerous disease by comparison. 

Case. — D. S., a robust and vigorous boy of seven and a half 
months, was always lively and healthy from his birth. The only 
trouble, for which now and then medical advice was procured, 
were slight broncho-catarrhs ; and the only thing remarkable in 
the external appearance of the child (being apparently brisk and 
healthy), was an uncommon paleness of the skin. Being exclusively 
nourished by breastmilk, he never once suffered from disorders of 
digestion, not even at the time when the first two lower incisors 
made their appearance. No particular- alteration in the state of 
his general health was perceived up to the 1st of March, 1857, on 
which day, towards evening, the child began to grow restless and 
troublesome, crying all night and seeming to be feverish. This 
symptom being the only one to be perceived, it was not much 
thought of, particularly when the child, towards morning of 
March 2d, fell asleep and rested fdr some hours. About 9 A. M., 
the same day, he had an evacuation of the usual quality, after 
which he again slept ; three hours later, about noon, he had 
another evacuation, with much pressing and straining, no faeces 
coming from him, but only some serous fluid mixed with a little 
blood, of red color. This symptom causing some alarm, I was sent 
for, and found, at 2 o'clock P. M., the following status prasens : 
Last normal evacuation at 9 o'clock A. M., first bloody one at 12, 
second bloody one at 1 P. M., of just the same quality as the first, 
with only a sign of fasces. The child is pale, but not more so than 
usually ; looks uneasy, without having a particularly timid or anx- 
ious expression; cries aloud, in a fierce and abrupt manner from time 
to time, as from colic ; the temperature of the surface in general, 
and of the head and extremities in particular, is normal. The 



53 

abdomen is soft to the touch ; there is nowhere a swelling to be 
felt • no pain effected by pressing ; percussion yields the common 
tympanitic sound. Pulse 100, somewhat small, but rhythmical. 
The child has not taken any food for the last four or five hours 
and has not vomited. My diagnosis, after the foregoing symptoms 
and results of examination, being merely symptomatic, a dose of 
calomel was given ; the prognosis being sufficiently favorable. 

March 3, 9 o'clock, A. M. — The child is much changed for the 
worse ; he is paler than ever, cheeks hollow, eyes sunk in the 
orbits ; he looks timid, anxious, restless ; cries often, but in a low- 
er and more languid voice, and his extremities move in a much 
less violent manner than yesterday. Nevertheless, there is no 
change in the general appearance of the patient, skin and circum- 
ference of the extremities have not lost their former appearance, 
and the embonpoint does not seem to be diminished. Abdomen is 
soft to the touch, and without pain, when pressed, neither inflated, 
nor sunk. Only there is, in the left inguinal region, immediately 
above the S Romanum, a swelling offering some resistance to the 
finger of a longitudinal form, of about one and a half inches, and 
a lateral width of about one inch, which was not discovered there 
the preceding day. Nowhere in the colon could another patho- 
logical alteration be found, particularly not in the ileo-ccecal 
region. No faeces have been evacuated since yesterday, but there 
have been from twelve to fourteen passages consisting each of a 
drachm or two of serous fluid, some three or four of them being 
colored with haematine ; all of them being, accompanied by pain- 
ful straining and pressing. The child began last night to throw 
up everything he swallowed, pretty soon after having taken it, and 
continued vomiting, for ten or twelve times, through both the 
night and the following morning, bringing up nothing but some 
mucus and bile. Always, after the child threw up, or evacuated 
his bowels, he seemed more languid, anxious, and nervous, his 
nervousness increasing in proportion to his weakness. He does 
not seem to be very desirous of drinking. His tongue is moist, 
slightly covered with some white mucus. Pulse 120, very small, 
but rhythmical. — Diagnosis : Invagination of the lower part of 
the colon descendens. — The treatment consisted in the immediate 
and repeated injection of warm water, in order to relieve, if pos- 
sible, the obstruction of the intestine, by pressing the invaginated 
piece out of the lumen of the bowel. Every effort proved unsuc- 



54 

cessful. The insufflation of the bowels, for the same purpose, was 
resorted to, and continued for a long while, with no better success. 
Both the injected water and air returned from the rectum at the 
moment the injections were being made ; the intestine filling with 
water or being inflated with air exactly as far up as to the place 
where the swelling could be felt in the left inguinal region. Only 
once did I believe that a small stream of air passed the invagina- 
ted bowel. It has been observed in many cases of invagination, 
that some gas escaped through the obstruction. I then left the 
child, who was to have a warm bath and some doses of Hydrarg, 
mur. and extr. hyosc. 

4 o'clock, P. M. — There is no material change. The child looks, 
if possible, more anxious, with a particular expression of his 
features, sometimes of nervous excitement, sometimes of total de- 
pression ; temperature of the head and extremities normal ; thirst 
increasing, pulse 130, small, contracted but regular. Patient 
vomited frequently since the forenoon, from twelve to fifteen times, 
and had about the same number of evacuations, which were even 
less bloody than the preceding ones ; almost wholly consisting of 
a serous fluid. I think the amount of blood excreted in all the 
passages for the last two days, did not exceed one drachm. The 
same treatment as before was resorted to, but proved just as un- 
successful. 

10 o'clock, P. M. — I saw the patient, in consultation with Dr. H., 
who recommend ol. crot. in large doses, in order to have the ob- 
struction removed at all events. Besides, injections of warm water 
and air were resorted to again and again, but all our efforts 
proved wholly ineffectual in overcoming the obstacle. The patient 
was in about the same condition he was in the afternoon, only 
more depressed in his strength, his motions being slower and 
sometimes as it were tired, and his voice sounding duller and 
lower than before. The eyes deeply sunk in the orbits ; the 
cheeks hollow ; pulse 136, smaller, but always regular. Vomiting 
occurred only four or five times since the afternoon ; bowels 
evacuated about as many times a serous and mucous fluid, without 
blood. Fecal matter appeared in neither of them ; no sign of it was 
ever brought up by vomiting ; only once there was a slight tinge of 
greenish color in the passage, which I felt at first inclined to con- 
sider as produced by the repeated doses of Hydrargyrum. 

March 4th, 9 o'clock, A. M. — No more vomiting has occurred since 



55 

last night, but the bowels excreted some five or six times the same se- 
rous fluid, which had, this time, the smell of bloodserum undergoing 
dissolution. The child is sinking rapidly (although the body does 
not lose very much), and is anxiously looking around for help ; 
the pulse is becoming smaller and weaker, 140 ; thirst increasing. 
The general condition of the patient remained the same during 
the day, the treatment being, as above described, repeated several 
times without giving the least relief. No more vomiting. 

March 5th. — The last day did not bring any particular change 
in the course of the disease. No vomiting occurred, nor were 
evacuations of the bowels so frequent as on the previous days, nor 
was there blood contained in them. Hands, feet, legs, became 
cold, pulse 150, 160, small, contracted, at last scarcely to be felt. 
No loud crying was any more possible, only a whimpering heard 
from time to time. All the while the abdomen was painless, only 
very little tympanitic. The eyes were so much sunk into the or- 
bits and the cheeks had become so hollow that it would have been 
impossible to recognize the child. During all the periods of the 
disease, the little patient was conscious of himself, and an anxious 
observer of what was going on around him : looking around for help 
as if knowing that every one was engaged in trying to relieve him ; 
sometimes depressed by his rapidly increasing weakness, sometimes 
disturbed by a sudden nervous excitement, sometimes troubled by 
the often repeated excretion of some drops of serous fluid from the 
bowels. Finally, conscious almost to the last quarter of an hour, 
the patient finished his four days' dying shortly before midnight. 

Post mortem examination, March 6th, 10 o'clock, A. M. — Only the 
examination of the abdomen was allowed. Rigor mortis. No 
unusual number of hypostatic spots on the back of the corpse. A 
great difference is perceptible between the general appearance of the 
face and the other parts of the body ; the face being extremely thin, 
the eyes deeply sunk in the orbits, and the subcutaneous fat of the 
cheeks gone, the rest of the body pretty nearly retaining its usual 
and normal roundness and fullness. The abdomen is not very 
much inflated with gas ; percussion yields a tympanitic sound ; to 
the touch it is equally soft on all parts, only a slight swelling as 
described above among the symptoms of the disease, in the left 
inguinal region. After the integuments were opened, the follow- 
ing appearance presented itself : Stomach normal, without con- 
tents : the jejunum and ileum moderately inflated with gas, very 



56 

few contents in them. The colon ascendens normal, the ileo- 
cecal valve shows nothing particular. The flexion between 
colon transversum and descendens not so manifest as it ought to 
be, being more a spherical curvature than a right angle. In the 
lower part of the colon descendens just above the S Romanum, a 
piece of the intestine has dropped, or is introduced into the next 
lower one, constituting a simple invagination of the colon, which 
was probably prevented by the S Romanum from growing larger 
than it is found to be. As usual in such cases, there is no difficul- 
ty in removing the invagination and bringing the several parts 
into their normal proportion. On the upper flexion of the in- 
testine, where the invagination is beginning, there is a manifest 
hyperaemia, on the lower flexion ; inside the invagination, there is 
extravasation of blood between the membranes. 

The colon transversum shows the following remarkable appear- 
ance : In its middle part, hanging down from the upper wall, 
there is a purely fibrinous coagulation, of a diameter of somewhat 
more than a third of an inch and two inches long, between the se- 
rous and the mucous membranes of the intestine, the muscular tissue 
being wholly destroyed ; the whole offering the clear signs of an 
extravasation having occurred long ago, of which nothing was 
left except the fibrine. Next to it there is another fibrinous co- 
agulum of the same size and nature, with the exception, that it 
appears, from some pieces of coagulated blood being still attached 
to it, and from its not being so hard and dense, somewhat less old 
than the former one. Third, there is a coagulation, not fibrinous, 
but really bloody, of fresh appearance, but firm and dense. The 
mucous membrane, which had been extended by the two former haem- 
orrhages, of which the fibrinous coagulations have remained, has 
been broken and lacerated by the third one. The last coagulation 
obstructs entirely the lumen of the colon, its walls being extended by 
and closely adhering to the fibrinous and bloody contents. It is 
evident, that the last extravasation was sufficient to shut the colon 
up, after it had become more and more narrow without injury to 
its functions, by its former local haemorrhages. 

The results of this post-mortem examination do not fully agree 
with those which Rilliet tells us are found in the majority of cases. 
In most of them the invagination was of a larger size, because in 
another part of the intestine. They mostly occurred in the colon 
ascendens, and, there being no hindrance to their further devel- 



57 

opment, enlarged to such a size, as to implicate, sometimes, the 
whole colon between the ileo-coecal valve and the S Romanum, in 
such a manner, that the flexures of the colon had wholly disap- 
peared and the ileum seemed as it were to immerge directly in the 
rectum or the lower end of the colon descendens. 

From this the positive statement of F. Rilliet (E. Barthez and 
F. Rilliet : Manual of the Diseases of Children, vol. 1, chap. xiii. ? 
art. 1), that in no age whatever can an invagination occur without 
the lower end of the ileum being the guide of the invaginated 
bundle, is evidently not in conformity with the facts, and is a pre- 
mature exaggeration. 

The invaginated portion, in the majority of Rilliet's cases had a 
dark red color, particularly the serous membrane ; the mucous 
membrane participating in the inflammation and congestion and 
covered with dark blood and mucus. In one case there was only 
a limited hyperemia and extravasation, although fully correspond- 
ing with the small extent of the invagination, the enlargement of 
which was apparently kept back by the normal impediment given 
by the flexura iliaca. It is generally stated, that in many cases 
an invagination of even a considerable extent cannot be felt dur- 
ing life ; so much the more remarkable is the case above described, 
in which the anomaly, although small, was discernible by the touch 
soon after its occurrence. 

A highly interesting feature in the whole number of facts re- 
sulting from the post-mortem examination, and not even thought 
of during the life of the patient, is the condition of the colon 
transversum. From the quality of the coagulations between the 
intestinal membranes, it is impossible to consider them as fresh 
productions ; besides, no opening of a bloodvessel could be found, 
by which the hemorrhage could have taken place ; weeks must 
have elapsed, since, at different times, fibrinous coagulations were de- 
posited. The last hemorrhage was a fresh one, since it obstructed 
the whole lumen of the bowel and was able to lead, by itself alone, 
to death. It is not the least interesting fact, amongst all the fore- 
going ones, that the extravasated blood coagulated so rapidly, as not 
to allow a drop or even the color of blood to escape into the intestine be- 
tween the place of hemorrhage and the invagination, not to speak of 
the small quantity of blood excreted by the passages, after the in- 
vagination had occurred. 

As to the symptomatic importance of either the obstruction by 
4 



58 

hemorrhage and the occlusion by invagination, there can be no 
doubt, in my opinion. I do not hesitate to say, that the symptoms 
of either of these anomalies, during life, must and would have 
been the same, if only one of them had occurred ; for the general 
effect of either of them, as well on the lumen and function of tho 
intestine as on the whole system must be equally destructive. Of 
some diagnostic importance is the fact, that, although the coagu- 
lations in the colon transversum were firm, solid, and as large as I 
have described, at all events a great deal larger and more solid 
than the invaginated part of the colon descendens, this one was 
soon discovered, while the former one could not be found, neither 
by repeated palpation nor percussion ; this is a fact, which cor- 
responds with Rilliet's remarks on the difficulty of finding, some- 
times, even large and solid invaginations in the living subject. The 
question arises, whicli of the two, the invagination, or the ob- 
struction of the colon by hemorrhage, occurred first. In my 
opinion there can be no absolute certainty about the answer ; but 
the following remarks may, perhaps, be thought sufficient to eluci- 
date the subject. It is a fact, that two local hemorrhages occurred 
a long time before the invagination took place, and on the same 
Bpot, where the third and last one was to occur later ; I do not 
feel enabled to say, whether there was a local predisposition to 
hemorrhage in only one blood vessel, it being too large or too 
thin, or abnormal in some other way ; or if there was a general 
disposition, in all the internal organs of the child, to hemorrhage, 
which resulted, perhaps, from a comparative hyperemia of tho 
abdominal organs, corresponding with the continual paleness of 
the child, while robust and healthy. A further fact is this, that 
the invagination occurred below the bloody obstruction of the 
intestine, and it is highly probable, that after the hemorrhage oc- 
curred, the muscular motion below it would have been, if not 
stopped entirely, at least diminished. If, on the contrary, the 
invagination had taken place above the hemorrhage, there would 
be more probability of the former having been produced by the in- 
crease of the anti-peristaltic movement of the intestine. As the 
facts are, I am rather disposed to say, that the invagination was the 
primary abnormity, and the cause of the small quantity of bloody 
discharge excreted through the anus ; and that the hemorrhage, to 
which a predisposition was clearly present and cannot be well de- 
nied, ensued as^soon as a strong anti-peristaltic motion of the mus- 



59 

cular tissue of the intestine set in. There are, then, two different 
causes of death, both almost equally dangerous ; both likely, with 
the same symptoms in the living subject. Finally, I have no 
doubt, that had no invagination occurred, probably the third hem- 
orrhage would have occurred a short time afterwards, and led to 
certain death, under the same or similar symptoms as the ones re- 
lated. 

As to the symptoms of the case reported, I have only a few re- 
marks to make, as the symptomatology given by Rilliet is most 
complete and able. His description fully corresponds with what 
I had occasion to relate. The only facts which, in my case, seem to 
be worthy of particular attention are these : that, first, the thirst 
of the child, which has been said to be usually not extraordina- 
ry, kept increasing in proportion to the duration, and to the ap- 
proximation of the fatal end of the disease ; and second, that vom- 
iting, never bringing up feecal matter, in opposition to what is 
always observed in cases of invagination in adults, stopped full 
two days before death, although the post-mortem examination did 
not give the least evidence of mortification, or even inflammation. 



ARTICLE VI. 

On the Oxysulphuret of Antimony as an Expectorant in Inflammatory 
Diseases of the Infantile Respiratory Organs* By A. Jacobi, M.D. 

The oxysulphuret of antimony, although mentioned by Basilius 
Valentinus in the fifteenth century, was made known for the first 
time in 1654 by Glauber, who prepared it while operating on the 
metallic antimony. Although generally well known from that 
time, there is scarcely another chemical preparation for which 
more different modes of preparation have been recommended, the 
chemical composition of which has been sought in more different 
ways, and the pharmaceutical and medical reports on which are 
more various and even contradictory. Now, it not being our 
intention to write a treatise on the chemical constituents of the 
oxysulphuret of antimony, we shall rest satisfied with merely laying 
before our readers what we sincerely believe to be the best method 
of preparing this remedy — one we have largely employed in our 

*New York Journal of Medicine for September 1858. 



60 

practice, and the results of which we are about to give to our pro- 
fessional brethren. 

The sixth edition of the Prussian Pharmacopeia (1846) gives 
the following prescription for preparing the oxysulphuret of 
antimony : 3 pounds of common carbonate of soda are dissolved 
in an iron vessel in 15 pounds of water, and are well mixed with 
a pound of lime made half fluid by three pounds of water, with 2 
pounds of the black sulphuret of antimony, and with 4 ounces of 
flowers of sulphur. This mixture is to be boiled for an hour and 
a half, the evaporating water being always compensated by filling 
up anew. The remainder is again boiled with 6 pounds of water, 
filtered and washed out with hot water. The fluid is made to 
crystallize. The crystals arc washed out with distilled water 
which has been mixed with ,^ ff of potassa, and afterwards dried. 
One pound of them is dissolved in 5 pounds of water, the whole 
filtered and diluted again with 25 pounds of water. A mixture 
of 4£ ounces of sulphuric acid and 8 pounds of water decanted 
after refrigeration is then added. The sediment is filtered, washed 
out with common water at first, and with distilled water after- 
wards ; is ][then pressed out between blotting paper, dried in a 
dark place, in a temperature of 77° Fahr.. reduced to powder, and 
kept in a dark, well-closed vessel. 

We omit the description of any physical and chemical qualities 
of this preparation, but give the analysis of Berzelius and H. Rose, 
the best analytical authorities. Both of these declare it to consist 
of 2 atoms of antimony and 5 atoms of sulphur (Sb 2 S 5 ), or of 
61.59 equivalents of antimony and 38.41 of sulphur. It has been 
called by Liebig the persulphide of antimony. 

We have given in full the mode of preparing this drug, which 
we make use of in our practice, for obvious reasons. The princi- 
pal objection to the oxysulphuret^of antimony has always been that 
it was so extremely liable to decomposition as not to be adminis- 
tered with any degree of surety. It has been asserted that there 
is always oxide of antimony formed in what is presumed to be the 
genuine article, and undoubtedly it is very often found. Sulphur 
too is formed, even in the shape of sulphuric acid, from decomposi- 
tion induced principally by the influence of air and light. As to 
the latter influences, and those of a similar kind, it is evident that 
it is not the fault of the chemical preparation, if the conditions 
necessary to its unaltered state are not given. Nitrate of silver 



61 

in solution, prussic acid, and many chemical substances require 
the greatest care in preserving them ; nevertheless, no one ever 
ventured to object to their administration in medical practice. 
It is true that great care has to be taken in preparing our medica- 
ment ; that it requires washing out finally in distilled water instead 
of common water ; that it needs to be dried slowly at a certain 
•temperature, and kept under peculiar external .conditions ; it is 
true, besides, that the many other ways of preparing it are unsafe 
and give rise to decomposition ; but after all, we see no reason to 
declare a substance to be subject to decomposition, if it can be 
proved that it is easily decomposed only when made by a wrong 
process and kept under unfavorable circumstances. 

Another objection to the medical use of the oxysulphuret of 
antimony has been, that it is soluble in alkalies, and might undergo 
decomposition in the stomach when the secretions happened to be 
abnormally alkaline. It has been asserted that it is decomposed 
too by acids, however slight they be. Now, we are unable to see, 
if indeed decomposition would easily take place, why a medica- 
ment ought not to be given for such a reason. If the secretions 
of the stomach are too alkaline, make them less so ; if acid drinks 
Avill decompose your medicine, do not administer them. There are 
a great many other medicines requiring the same and more pre- 
cautions ; it has never been urged as a reason against the medici- 
nal use of the nitrate of silver, that its tendency to decompose, 
either by the secretions of the stomach or by ingested food, makes 
it unfit for internal administration. 

The truth is, that the oxysulphuret of antimony has not been in 
general use for a long time ; twenty-five or fifty years ago it was 
highly estimated, but the majority of writers at the present day, 
appear to scarcely know of its existence. In order to show this, 
we will give some literary notices, particularly such as have been 
taken from authors on infantile diseases, it being our object to 
communicate a few observations on the mode of operation of the 
oxysulphuret in diseases of children, and to recommend it for 
further use. We will premise that we desire our readers to give 
their special attention to the dose of this remedy, it being our firm 
conviction, after a great number of observations, that the want of 
success often complained of in its administration, and the want of 
confidence in its power, is but the consequence of an entire mistake 
as to the amount to be given. 



02 

Behrcnds administered one grain every two hours in the second 
stage of pneumonia, when expectoration was deficient and strength 
was failing, in combination with camphor and benzoic acid. Jahn 
gave one grain three or four times a day, in pulmonary catarrh, 
with opium and camphor. Richter gave one grain twice a day, 
in acute catarrh of the stomach, with tartrate of potassa, and two 
grains twice a day, iji chronic arthritis, together with calomel and 
aconite. Brera employed a fourth of a grain every three hours, 
in painful arthritic affections, with morphine. Lessing gave one 
grain and a half three or four times, in chronic pulmonary catarrh. 

From these quotations it is evident that it was impossible from 
the manner of administering this remedy, in combination with 
others frequently of the same class, to decide on its effects ; and 
further, that the dose seldom exceeded one grain, and only in ex- 
ceptional cases reached as high as six or eight grains in the 
course of a day. It is, moreover, to be kept in mind, that such 
are the doses administered to adults. 

In looking over the literature of diseases of children, we find 
as many negative as positive facts ; that is to say, there are as 
many writers who do not even mention the name of this article, 
as there are who recommend it highly. In the oldest paediatric 
literature, even in Nils Rosen von Rosenstein's work, the oxy- 
sulphuret of antimony is not mentioned. Jahn (1803) says, it has 
been recommended by some in hooping cough. 

Henke gave half a grain twice a day, together with half a grain 
of powdered herb of belladonna, in hooping cough. Tourtual 
gave a quarter of a grain, with three grains of sulphur, three 
times a day, in pseudo-croup, and the second stage of inflamma- 
tion of the trachea. Dornbliith used a quarter of a grain every 
three hours, in pneumonia of children of one year of age. Wendt 
gave the same quantity, in the like disease, four times a day, to 
children of from three to four years of age. Hinze gave half a 
grain every two hours, with oxide of zinc and musk in hooping 
cough. Meikisch, who wrote his " Contributions to the Knowl- 
edge of the Infantile Organism" at about the same time (1825), 
neither recommends nor mentions it. Wenzel (1829) prescribed 
it in pneumonia, to a child of one year of age, a third of a grain 
to be taken three times a day ; to a child of two years of age, 
either half a grain four times a day, or a quarter of a grain twice 
a day, or a sixth of a grain to be taken every hour ; in measles, to 



63 

a child of two years of age six doses of half a grain each, every 
two hours ; to a child, one year old, twelve doses, of an eighth of 
a grain each, to be taken four times a day. Ilau (1832) considers 
it to be a powerful expectorant, in a dose of a sixth or a quarter 
of a grain, in infantile pneumonia, after the hight of inflammation 
and fever is over, and where the accumulation of phlegm in the 
bronchia forbids free breathing. Meissner (1832) mentions it as 
an expectorant, but does not appear to expect much of its admin- 
istration. After this period, the oxysulphuret of antimony is sel- 
dom mentioned, and never so strongly recommended as before. 
It is true, that Cruse (1839) in his work on infantile bronchitis, 
speaks of it as an expectorant, but he frankly states that he pre- 
fers the anisated liquor of hartshorn. 

Fuchs, in his monograph on infantile bronchitis (1849), merely 
mentions its name, but as early as 1837, Seifert did not think 
proper to name it among his medicinal agents, in his monograph 
on the broncho-pneumonia of new-born infants and nurslings. 
Moreover, there is perhaps no manual on infantile diseases, of the 
last twenty years or more, which takes the least notice of it, 
whereby sufficient proof is given, that the recommendations of 
some of the earlier writers were not confirmed by the experience 
of their successors. In the manuals of the following authors : 
Vallcix, Barrier, Underwood. Coley, Evanson and Maunsell, 
Stewart, Eberle, Legendre, Dewees, Hennig, Meigs, Condie, 
Churchill, Bcdnar, West, Rilliet and Barthez, Bouchut, and Tan- 
ner, not the slightest mention is made of the effect of the oxysulph- 
uret of antimony as an expectorant. 

In the works of some of the latest writers we find similar re- 
marks. Anton, in his collection of prescriptions, employs in 
pneumonia of children of from eight to twelve years of age, a 
quarter or one-half of a grain. Joseph Schneller, in his " Materia 
Medica, applied to the Diseases of the Infantile Age" (1857), 
while saying, that it is administered in long continued catarrh, 
bronchial blennorrhea, in croup, when the more dangerous symp- 
toms are disappearing, in hooping cough, as a diaphoretic and 
expectorant, speaks of doses of an eighth or a quarter of a grain 
each, to be taken three or four times a day. The pharmaceutical 
writers of the present day offer similar remarks : Schroff, of 
Vienna, speaks of several daily doses of from a quarter of a grain 
to a grain each ; Schuchardt, of Gottingen, has from a quarter of 



64 

a grain to two grains, and allows even five grains in exceptional 
cases. Oesterlen, of Heidelberg, whose doses are believed in 
Germany to be generally very high, speaks of doses of from one 
to four grains, to be given several times a day. Sobernheim recom- 
mends a quarter or one-half of a grain, sometimes even one or 
two grains, to be administered two or four times a day. All these 
doses are considered to be normal doses for adults. While, then, 
authors on pharmaceutics and therapeutics deem it their duty to 
register anything that has been said on any pharmaceutical object, 
pathologists of the present day, especially such of the last year, 
as Wunderlich, Leubuscher, Niemeyer, either entirely overlook 
this antimonial remedy, or have very little indeed to say in its 
favor. Finally, from " Thomson's Conspectus of the British 
Pharmacopoeias," seventeenth edition, 1852, we copy the follow- 
ing notes on the oxysulphuret of antimony : " Operation : emetic, 
diaphoretic, cathartic, according to the extent of the dose ; alter- 
ative, used now only for forming Plummer's pill. Use : for 
chronic rheumatism and obstinate eruptions. Seldom ordered. 
Dose : gr. i. to iv. twice or thrice a day, in a pill." The " Dispen- 
satory of the United States," eleventh edition, p. 929, pronounces 
the very same opinion : " The precipitated sulphuret of antimony 
is alterative, diaphoretic, and emetic. It is, however, an uncer- 
tain medicine, as well from the want of uniformity in its composi- 
tion, as from its liability to vary in its action with the state of the 
stomach. It is seldom given alone, but generally in combination 
with calomel and guaiacum, in the form of Plumnier's pill, as an 
alterative in secondary syphilis and cutaneous eruptions, or con- 
joined with henbane or hemlock in chronic rheumatism. During 
its use the patient should abstain from acidulous drinks. Its dose 
as an alterative, is from one to two grains twice a day, in the form 
of a pill ; as an emetic, from five grains to a scruple." 

From the facts thus selected from the authors of more than 
the last half century, it becomes evident that there is a great 
variety of opinions as to the operation of the oxysulphuret of an- 
timony. While believed to be, at a certain period, a highly valu- 
able remedy in different morbid conditions of the organism, or 
inflammations of the respiratory organs, scrofula, rheumatism, arth- 
ritis, blennorrhoea, diseases of the lymphatic glands, of the skin, 
and of the pulmonary nerves, it has been again considered to be 
bo valueless as not to attract the least attention from the medical 



65 

writers of the last twenty years. We believe the reason may be 
found in the fact we insisted upon above, that the majority of 
preparations have been uncertain, because of their being badly 
made ; and in the further fact, that medical practitioners followed 
more the theoretical impression of the caution required by anti- 
monial medicaments in general, than their own careful observa- 
tions on the mode and strength of the operation of the precipitated 
oxysulphuret. 

Thus, what we are going to prove next is, that the doses given 
have been incompetent and insufficient for any considerable result : 
and that what is put down as the highest dose to be administered, 
is scarcely proper to begin with even in the slightest affections. 

It is well understood by our readers, that the larger doses of 
one grain, etc., as above mentioned, are to be taken as the quanti- 
ty allowed for adults. If these doses were to be reduced to the 
proportion necessary for infantile diseases, we shall, after having 
reported our practice and the results of our doses, appear more 
justified in saying that the difference of opinion and the want of 
confidence is entirely due to the insufficiency of the doses admin- 
istered. 

Before making some general remarks on the indications, we an- 
nex the subjoined list of cases taken from the journal of the chil- 
dren's department of "the German Dispensary of the City of New 
York," which, for the use of our readers, has the number on the 
journal, the sex and age of the patient, the diagnosis, and the do- 
ses of the oxysulphuret of antimony ; all the cases occurring in the 
first eight months of 1858. We shall add some observations taken 
from our private practice : 



66 



1 

1 

3 
O 
-> 








I 






d 


1 


m 
< 






Yr. Mo. 


7 


F. 


2 


9 


M. 


3 


158 


F. 


9 


216 


F. 


6 


266 


M 


5 


281 


K. 


4 


290 


M. 


1 6 


300 


r. 


9 


311 


F. 


3 


313 


F. 


3 


326 


M. 


2 6 


355 


M. 


7 


370 


M. 


1 5 


397 


M. 


3 


410 


F. 


2 


457 


M. 


1 8 


486 


M. 


7 


641 


F. 


1 2 


610 


M. 


2 2 


628 


If. 


4 6 


691 


F 


6 


709 


F. 


1 7 


826 


F. 


7 


981 


M. 


5 


1000 


M. 


1 1 


1134 


M. 


7 


1144 


M. 


2 


1160 


M. 


2 


1168 


M. 


1 6 


1172 


M. 


1 6 


1176 


F. 


3 


1261 


M. 


1 1 


1370 


F. 


2 


1373 


M. 


1 6 



Disease. 



Pneumonia, left, inf. 
" Rup. 
bilat. sup. 
Hooping cough, cat. 



pneumo'a 
Pneumonia, left, inf. 

after measles. 
Hooping cough, cat. 
Pneumonia. 

" left, sup. 

Bronch, cat. 

ii II 

Hooping cough, cat. 
Hronch. cat. 
Hooping cough, cat. 
Bronch. and gastr. cat. 
Bronch. cat. , emphys. 
Hooping cough, cat. 

Bronch. cat. 
u 

Hooping cough, cat. 
Pneumonia, left, inf. 
Pneumonia, left, sup. 
Ditto, Hooping cough. 



Bronchopneumonia. 
Pneumonia, h. cough. 

" right, middle. 
Hoop, cough, br. cat. 
Pneu. right, sup., tub. 
Pneumonia, left. 
Pneumonia, right, inf. 



Doso of oxysulph. of 
antim. 



1 % gr. every 2 hours, 
t gr. 4 times a day. 
I gr. every 2 hpurs. 
% gr. 4 times a day. 
l^gr. 

it it 

1 % gr. every 2 hours, 
i gr. 4 times a day. 
i gr. " 

IH gr. 



1 gr. 
>>£ gr. 
>- gr. 
I gr. 

1 gr. 

2 gr. 
'%gr. 
t gr. 
1 gr. 
i>4gr. 
l^gr. 
I gr. 
I gr. 
I gr. 

Kgr. 



l gr. 

I gr. 

1 gr. 

' gr- 

i gr. 

1 gr. 

2 gr- 
I gr. 
I gr. 

l^gr- 

1 gr. 

2 gr. 



every 3 hours. 

every 2 hours. 

3 times a day. 
every 2 hours 

4 times a day. 
every 3 hours. 

3 times a day. 

4 times a day. 
every 2 hours. 
4 times a day. 

every 3 hours, 
every 2 hours. 



4 times a day. 
every 2 hours. 



3 times a day. 
every 2 hours. 



4 days. 
12 " 



4 days. 

2 " 

12 " 

2 " 



12 " 



Combined with 



Extr. bellad. J£ gr. 



Sulph. chin. )4 gr. 

Extr. bellad. >£ gr. 
Sulph. chin. >i gr. 



Extr. bellad. >£ gr. 

Extr. bellad. 1-6 gr. 
Sulph. chin. >£ gr. 

Extr. bellad. JJ gr. 



Extr. bellad. 1-6 gr. 



Extr. bellad. % gr. 



Extr. bellad. 1-6 gr. 
Sulph. chin, X £ r - 



Of this number two patients died ; one of pneumonia combined 
witli measles, the other of quite recent pneumonia. of the inferior 
lobe of the left lung, for which she had not been under treatment, 
after her hooping cough subsided. All the others recovered. 

The general result of the dispensary was also obtained in our 
private practice. We remember a great number of patients of a 
year and under, who took a grain of the oxysulphuret of antimony 
every two hours, even every hour, without vomiting more than once 
or twice, some without vomiting at all. The same occurred with 
children of two or three years of age, who took doses of two grains, 
four, and even six or eight times a day, without showing any oth- 
er result than the desired one. We recollect the case of a boy of 
two years four months of age, in the basement of No. 158 Leonard 
street, who while suffering from a severe double pleuro-pneumonia, 
after having for a while taken somewhat smaller doses, took for 



67 

four days, either a dose of two and a half grains every hour, or of 
five grains every two hours ; he did not vomit more than once, 
and that easily, in twenty-four hours, and did not show more than 
a trace of the doses in the passages, of which he had one daily, 
before the end of the second day. The pathological alteration of 
the lungs and pleura was such, that the prognosis was unfavorable 
from the beginning ; but the purpose of the administration of large 
doses of the remedy was readily accomplished as the patient, in 
consequence of his easy and copious expectoration, avoided the 
death of suffocation. 

A boy of six months of age has been under our care for the last 
week, who has taken, every other hour, a dose of a grain and a 
half, while in the second stage of pneumonia of the left lung. It 
is true that the infant vomited after the first four doses, but he did 
not feel the worse for it ; only on the third day of his taking the 
remedy it would be found in the passages, which were riot particu- 
larly changed from their general normal appearance. When, in- 
deed, children are vomiting after the first, or one of the first, doses 
of the medicament, we do not see any harm in it ; the bronchial 
secretions cannot be removed in a quicker and generally safer man- 
ner. 

We omit giving further special reports on individual cases ; the 
diseases we refer to are so common as to be the daily anxiety of 
every practitioner ; and every one will be capable of proving the 
accuracy of our observations, and the truth of our remarks very 
speedily. After the favorable results above reported, by means of 
large doses of the oxysulphuret of antimony, we trust the profes- 
sion will resort to larger doses, and thus again introduce into their 
practice a long-forgotten remedy. 

But it cannot be too strenuously urged, that the indications for 
the use of this medicine in inflammatory diseases of the infantile 
respiratory organs, ought not to be overlooked. Whoever con- 
tends against the fever of the first onset of pneumonia with the 
oxysulphuret, will feel sadly disappointed as to the final result. 

Whoever treats acute bronchitis in the same manner, will soon 
become aware of his mistake. Its operation is only to liquefy 
the secretion of the mucous membranes of the respiratory organs. 

We think it may be well compared to the preparations of mer- 
cury ; in the same manner as these effect the liquefaction of plas- 
tic exudations and alter the plastic quality of the blood, the oxy- 



68 

sulphuret of antimony effects the liquefaction of the secretions of 
the mucous membranes of the respiratory organs. How this is 
done it is impossible to determine. At all events some effect on 
the respiratory nerves is also produced, and possibly much of the 
result is the consequence of their altered functions. How far, be- 
sides, the mucous membranes of other systems are subject to the 
operation of the medicine, our experience does not fully enable 
us to say. 

It has been used, and is used by us, in inflammations of the larynx, 
trachea, bronchi, bronchia, and lungs. After the inflammatory 
fever is removed, and the disease has reached its highest develop- 
ment, it ought to be given alone, or in combination with other 
agents, in full doses. Not before this stage of the disease can this 
effect be obtained. We have generally been fortunate enough to 
see a speedy recovery follow its administration. We need no 
add, that it renders the best services in common bronchial catarrh, 
where full and speedy expectoration is wanted. Such were the 
indications for the use of the oxysulphuret of antimony at the time 
of its cautious administration, long before it appeared to be almost 
entirely forgotten, particularly in the United States and Great 
Britain. But the want of knowledge as to its proper use, seems 
to have impaired the success due to it when used right. 

There is but one writer, Neumann (1840), who went as far as to 
prescribe to adult patients, doses of six or seven grains without 
producing vomiting, and to confess that he did not see an objec- 
tion to giving, if necessary, a dose of twenty grains. To this re- 
mark, and to the fact, that this remedy has been recommended, and 
administered by us also, in a few large doses daily, in pulmonary 
emphysema, and, finally, to a remark in Rilliet and Barthez's 
Manual (vol. iii. chest, chap. viii. art. ix.) on the use of from five- 
sixths of a grain to thirteen grains, in some cases, of the mineral 
kermes, another, but not so safe a preparation of antimony, we 
owe the first idea of introducing into our practice the oxysulphuret 
in large doses. We had abandoned it years ago, tired and disap- 
pointed with the entire want of success in the use of the small 
doses taught by the manuals on materia medica. 

We are aware of the objection to large doses of this remedy, 
that it cannot but sometimes produce excessive vomiting. Such 
a case might occur, but could easily be remedied by diminishing 



69 

the dose ; there is no remedy against which individual idiosyn- 
crasies will not prove rebellious, although given in small doses. 

Generally, vomiting will not prove of any importance ; at least 
we have been taught so by experience. Furthermore, it is to be 
kept in mind that there are influences which may be avoided by 
careful management ; it is well known, for instance, that nausea- 
ting remedies, although in small quantities may operate as emetics ; 
thus, a little tartar emetic will, when dissolved in a large quantity 
of water, prove to operate as an emetic and purgative. On this 
principle the oxysulphuret of antimony, too, could have a nausea- 
ting effect, when brought into further contact with the whole sur- 
face of the mucous membrane of the stomach ; it is even possible, 
in our opinion, to produce diarrhoea by diluting the remedy by co- 
pious drinking of sugar-water, or similar things. All this will 
have to be avoided. 

We are less afraid of diarrhoea being produced by spontaneous 
chemical decomposition, especially by formation of the oxide of 
antimony, for acids and alkalies can be avoided, and kept from 
coming into contact with the oxysulphuret, and diet may always 
be regulated according to circumstances. Further, we scarcely 
recollect a case where diarrhoea of any importance followed 
the administration of our medicament ; at all events, there was 
none, the cause of which we could look for in the antimony. 
Third, our preparation, when found in the evacuations of the 
bowels, is not decomposed. 

As to the fact, that the oxysulphuret of antimony is found in 
the passages a day or two, or three, after commencing its admin- 
istration, we have had the objection made to our large doses, that 
they are worthless because of their leaving the organism without 
exercising any influence. Now we have often experienced the fact, 
that no difference can be found as to the time (usually the second 
or third day) when the medicament is visible in the fasces, whether 
it has been given in large or small doses. Besides, we do not 
know exactly what the mode of its operation is ; perhaps it is not 
necessary at all to have it entirely dissolved and taken into the 
system in order to see its full power developed ; and besides, we 
know very well that other remedies appear in the faeces very soon 
after their having been swallowed, and, like the iron in its several 
forms and combinations, lose nothing of their medicinal effect. 



TO 

The last objection to the oxysulphuret of antimony has been, 
that it belongs to the class of nauseating remedies, and will, un- 
doubtedly, when taken any length of time, affect the appetite of 
the patients, and thereby injure their strength. Now, we desire 
our readers to remember what the indications are which require 
its administration. An inflammatory fever has just been removed 
by an antiphlogistic treatment ; the assimilating functions are al- 
most entirely gone ; there is still a fever, and the necessity, at the 
Eame time, of furthering the secretion of the mucous membrane and 
removing exudation. This is the period for the employment of 
this drug. The appetite cannot be affected by the medicament, 
for there is none ; if there was, in spite of fever and inflammation, 
it would be better to impair it, in order to keep the digestive func- 
tions as inactive as possible. At a later period of the disease, or 
where danger arises from anaemia, it is certainly necessary to think 
of the stimulation of appetite, digestion, and assimilation. Then 
the oxysulphuret of antimony may be combined with iron, with 
quinine, with rhubarb, or nux vomica, etc., each of which has its 
own indication. One remedy cannot answer all indications. 

We have a single additional remark to make. Our therapeu- 
tical observations have generally taught us, that wherever a rem- 
edy is really and fully indicated, it is tolerated in large doses. 
Thus, we have the firm conviction that the large doses of the 
oxysulphuret of antimony, recommended above, will surely be adop- 
ted in general practice, as has been the case with the tartar emetic 
since the times of Peschier and Rasori, and with the opium since 
the ingenious and important discoveries of Clark. 



ARTICLE VII. 

On the 1 Etiological and Prognostic Importance of the Premature 
Closure of the Fontanels and Sutures of the Infantile Cranium. 
By A. Jacobi, M.D. 

The development of the various organs of the infantile body 
generally proceeds in an equable measure. Only the skull, with 
its contents, seems sometimes to form an exception to this rule. 
Compared with the whole body, the infantile head is large ; its 
blood-vessels are in due proportion to its size, and before the 
closure of the sutures, the blood-vessels of the brain and of its 



71 

membranes, finding less resistance from outside pressure, are 
expansible in a higher degree than are those in other parts of the 
body. In consequence, then, of increased upward motion of the 
blood, we find that in children the development of the skull, jaws, 
and teeth, and the frequency of inflammatory and exudatory 
diseases of the brain and its membranes, go hand in hand ; they 
are coordinate effects of the same cause. The bones of the infan- 
tile body develop themselves with the same equability as its other 
parts. Protracted teething, retardation of the closure of the 
fontanels, retardation of walking, usually coexist, and are not at 
all favorable symptoms, being but too frequently the first signs of 
rachitis. Nor is prematurity of teething, of closure of the fontan- 
els, and of walking, very rare. One fact, however, must not be 
overlooked here, viz., that the head and upper extremities, in 
their normal state, contain more lime, proportionately, than the 
pelvis and lower extremities. This fact is well understood, and 
explains the pathological alterations as well in the lower extremi- 
ties as in the cranium, morbid tendencies going to develop mollifica- 
tion in the former, sclerosis in the latter. Indeed, all the cases 
of genuine sclerosis of the cranium, that have been reported in 
literature, seem to have commenced in early life. 

Other exceptions to the rule, in which the skull is developed in 
proportion to the other bones, are frequently found, the causes of 
which can hardly be defined. Both parental constitution and ma- 
ternal blood are, no doubt, of some influence. This is, however, 
not without restriction, as robust children are frequently born of 
weak mothers, and vice versa ; but it has been shown by Spondli* 
that large maternal skulls have a great influence on the develop- 
ment of that of the infant. 

Climatical and typical peculiarities seem also to account for 
some of the differences in the formation of the cranium. Thus, 
Edwardsf asserts that in the West Indies the coronal juncture is 
broad, and remains open for a longer period than in cold coun- 
tries. As to the custom of the natives, of pressing downwards 
the os frontis and os occipitis, he thinks it might be explained by 
the instinctive endeavor to effect an earlier closure of the fonta- 

* Heinrich Spondli, die Schadeldurchmesscr des Neugebornen undihre Bedeutunq. Ztirich 
1857. 

fL. A. Gosse : Essai sur les deformations artificielles du crane. Paris, 1855, p. 23. — 
Edwards : History of the West Indies. 



72 

nels and the cranial junctures in general. Schoepf Merei* thinks 
himself justified in assuming that the large fontanel closes later 
at Manchester, England, than at Pesth, in Hungary. Many simi- 
lar facts are brought to light by comparative observations. Thus, 
we are informed by Mauthner,f that the skulls of Slavonian chil- 
dren are more compact, disproportionate, and clumsy, larger in 
every dimension, and more subject to hyperostosis, than those of 
Hungarians. And Gratiolet observed, that the cranial sutures 
close later in the white race than in the black one, and that the 
coronal suture, being the first to ossify in negroes, is the last 
to do so in Caucasians. 

It is to be considered a law, that the incisors cut, before the 
closure of the large fontanel takes place, this being followed only 
by the ability of walking. In the average, the first incisors make 
their appearance at the age of six or seven months, the large fon- 
tanel is closed at twelve, walking ensues at thirteen months. 
By closure of the large fontanel, however, I do not mean its en- 
tire ossification, as this is consummated only with the third year. 
Some weeks after birth, the large fontanel has a size of a square 
inch, or nearly so ; somewhat less in small and weak children, 
somewhat more in large and robust ones. From a merely patho- 
logical point of view, we take the closure of the fontanel to be 
complete, when the fibrous bridge between the osseous margins 
gives way no longer to the pressing finger, and no pulse can be 
felt through it. The fontanel is seldom closed before the first in- 
cisors have broken through ; walking is rarely possible before the 
closure of the fontanel. Sometimes, however, I have seen children 
walk without a single tooth in their mouth. Merei relates the 
case of a child who walked at fifteen, had his first incisors at six- 
teen, and whose large fontanel had the size of about one-half of a 
square inch at nineteen months of age. Nevertheless, the child 
was lively, sensitive, not rickety — which seems fully to prove, that 
irregularities in the development of the osseous system may occur, 
sometimes, without any morbid symptoms. 

The best evidence of a normal development is the regular ap- 

* A. Schoepf Merki : On the Disorders of Infantile Development, and Rickets, Preceded 
by Observations on the Nature, Peculiar Influence and Modifying Agencies of Temperaments. 
London, 1855, p. 116. 

t Entwickelungsanomalieen am Kinderschiidel. Oesterreichische Zeitschrifl filr Kinderheil- 
kunde, Nov., 1856, p. 52. 



73 

pearance of the teeth. Eichmann* reports four hundred observa- 
tions on dentition, from which he draws the following conclusions , 
The first inferior incisors break through between the 28th and 
32d week ; the first superior ones, between the 36th and 40th ; 
the first anterior molar teeth, between the 48th and 54th week ; 
the canine teeth, between the 16th and 18th; the first posterior 
molar teeth, between the 22d and 24th month. At 27 or 30 
months there are 20 teeth formed ; about this time, or shortly 
after, the large fontanel has finished its entire and permanent os- 
sification. 

Sometimes, however, and indiscriminately so with robust or 
feeble children, the first incisors cut in the fourth or fifth month. 
Merei reports the case of a child which had his first incisor at 
three months of age, and had fourteen teeth when eleven months 
old. In newborn children teeth are not frequently found. We 
are toldt that Louis XIV., Richard III., and Mirabeau, were born 
with teeth ; one case is reported by Churchill ; in another case: 
Whitehead, | in order to facilitate suckling, removed from the 
inferior jaw of a newborn child two teeth, which were reproduced 
simultaneously with the appearance of the canine teeth. One case 
is reported by Fleming, one by Denman, nineteen by Haller. Nor 
are remarkable cases of unusually protracted dentition more fre- 
quent. Among Eichmann's 400 cases, there are a few, in which 
the first tooth cut at the twenty-second month ; in a case reported 
by Churchill, it cut in the seventh year ; and Merei knew a child 
whose large fontanel closed at four years of age, but whose mouth 
was still toothless at six.§ We have observed, in the " German 
Dispensary of the City of New York," a child of thirty-four 
months, without a single tooth, and whose fontanel did not even 
begin to close. The record of the children's department of the 
Dispensary contains another similar case of a child two years old. 
There are, moreover, irregularities sometimes, defying accurate 
explanation, but worthy of notice. There is, in the .written records 
of the meetings of the Society of German Physicians (Feb. 27th, 
1857), the case of a man of 63 years, whose large fontanel was 
open ; also a case of a girl of 14 years, of feeble constitution, with 
well developed mental faculties, and a large head. Her father has 

* Schmidt's Jahrbilcher der In-und auslandischen gesammten 3Iedicin. 1853, No. 12. 
t Fleetwood Chukcuiix. M.D. : Diseases of Infante and Children. Second Am. Ed., 
p. 417. {Merei, p. 118. § L. C, p. 119. 

5 



74 . 

been syphilitic sometime during his life. Frederick C. Stahl re- 
lates the case of a man of 50 years of age, and Eulenberg and 
Marfels* report the same anomaly to have occurred in a cretin of 
20 years of age. 

The following results of Eichmann's seem to be worthy of a 
particular consideration : Of twenty healthy and robust children, 
the fontanel was closed in ten at from eleven to thirteen months ; 
in five at thirteen ; in two at fourteen ; in two at ten ; in one at 
fifteen. In fourteen of them, the first teeth cut at from six to eight 
months ; in four at from eight to nine ; in two before the sixth 
month. Consequently there is, in healthy children, an interval 
of from four to seven months between the cutting of the first in- 
cisors and the closure of the large fontanel. 

Of eight feeble or sickly, but not rickety children, the large 
fontanel was closed in six at from eleven to thirteen ; in two at 
from thirteen to fourteen months of age. In seven of them the 
first incisors cut from four to seven months before the closure of 
the fontanel ; in one the cutting of the first tooth, which took 
place at thirteen months, was directly succeeded by the closure of 
the fontanel. 

Of eight rickety children, the fontanel in three was closed in 
the thirteenth month ; symptoms of rachitis developed themselves 
immediately afterwards. The incisive teeth came at the regular 
time ; the other ones too late. In three the closure of the fon- 
tanel took place between the sixteenth and nineteenth month, the 
first tooth having cut at twelve months, and being followed by 
the rest in rapid succession. In one the large fontanel was open 
at nineteen months ; the first teeth cut at the regular time, but at 
eighteen months there were only eight of them formed. In one, 
rickety also before the eleventh month, the fontanel was not 
closed, and the mouth toothless, at the age of tweuty-five months. 

A. Schopf Merei and J. Whitehead have published, in their 
first report on the Children's Hospital of Manchester, England,t 
their observations on the closure of the large fontanel, made in 
children from five months to three years of age. They state at 
once, that children of one and one-half, two, or three years, in 
whom the large fontanel was found open, showed a very unfavor- 

* Hermann Eulenberg und Ferdinand Marfels, Zur pathologischen Anatomie des 
Cretiniemue. Wetzlar, 1857. 
t Journal for Kinderkrankheilen, 1857. March and April. 



7o 



able general development ; they being very late in teething, 
feeble as to their locomotory organs, and exhibiting anomalies in 
the size and shape of cranium and thorax, and symptoms of uni- 
versal rachitis. Some children who had been walking from 
their eleventh, twelfth, or thirteenth month, and had some sixteen 
teeth, had their fontanel open when eighteen months old ; in 
others the reverse took place, the fontanel being closed before the 
appearance of the very first tooth. Among the whole number of 
well developed children, observed by our authors, the fontanel was 
At the age of 6-7 months closed in 3, open in the rest. 



8 


u t 


' 8 


H 


r< 


9 


a t 


■ 2 


U 


u 


10 


a < 


' 2 


H 


u 


11 


u t 


• 4 


ft 


11 


12 


a i 


' 11 


11 


3 


13 


M t 


1 13 


It 


3 


14 


U I 


' 13 


it 


2 


15 


U t 


1 9 


u 





15-18 


It . 




each, 


except 2. 



1 


u 


ft 


3 


II 


14 


1 


u 


12 


5 


u 


11 


4 


(( 


12 


13 


M 


14 



After the eighteenth month the fontanel was not found open in 
any well developed child. 

Among viciously developed children the fontanel was 

At the age of 7 months, closed in 1, open in the rest. 
11 
12 
13 
14 
15 
" 16-36 

In a very small number of children, who exhibited a general 
state of very bad development and general rachitis, the fontanel 
was even found open in the third or fourth year of age. 

From these facts the conclusion may be safely drawn, that the 
large fontanel is closed, in well developed children, at or before 
thirteen months of age, and that it is open at the same period of 
life, or later, in a large majority of badly developed children. It 
must not be supposed, however, that the diminution of the size of 
the fontanel takes place gradually. Schopf Merei and White- 
head prove by a large number of observations on healthy and 



70 

well developed children, that the fontanel is largest at from five 
to seven months, the size being from one to two inches from one 
margin to the other ; Liharzik* arrives at a similar result, and 
ElsaDSsert considers the age of nine months as the period at which 
the large fontanel ceases growing, and commences its rapid ossifi- 
cation. 

The completion of the crania^ sutures is often delayed in spite 
of a normal condition of the brain. Sometimes the ossification in 
newborn children is deficient ; in such cases it may have started 
from the usual points, but the bones are thin, their periphery 
fibrous, or there are fibrous gaps in the osseous structure. Both 
the circumference of the skull, and the general development of the 
children, may be entirely normal in such a state of the osseous 
structure of the cranium. Sometimes, however, abnormities are 
found, as, for instance, hydrocephalus. In some cases," the fault 
has been attributed to constitutional diseases of the parents, to 
pathologico-anatomical peculiarities of the maternal pelvis. Ab- 
normal sutures also may be found, the ossa frontis, occipitis, 
temporum, parietalia, remaining each divided as in the foetal state. 
Or there are the so-called ossa Wormiana, results of normal ossi- 
fication, but proceeding from an unusual abundance of starting 
points, in groups of sometimes such a remarkable number, that 
Meckel met with and counted two hundred of them in one in- 
dividual. 

It is, however, the premature solidity of the cranial bones, 
which we consider as our special subject in these pages. Some- 
times it is inborn, and the result of inflammations suffered during 
fcetal life ; in such cases an osseous elevation is sometimes felt 
along the sutures. Otto records, in his report."!: on the specimens 
of the Anatomical Institute of Breslau, the cranium of a newly- 
born child, with very small eyes, face and orbits were extremely 
small, the frontal bones firmly joined, formed a prominent edge. 
Dr. Haase§ met, in a newly-born child, with a piece of bone, 
entirely filling and covering the large fontanel. Trista || deliv- 

* Franz Liharzik, das Geselz da mensehliehen Waehsthums und der unter der Norm 
zuriickgebliebene Brustkorb als die erste und wichtigstc Vrsache der Rliachilis, Scrophulose 
und Tuberculosa Wien. 185S. 

t C. L. Ehcesser, der Weiche Ilinterkcpf. Stuttgart und Tubingen. 1843. 

X 1830. § Gemcinsame deutsche Zeitschrift fiir Geburlskunde. iv. 3. 

|| Rust und Casper Kritisches Rcpertorium fur die gcsammle Jleilkunde. xxviii. p. 121. 



77 

ercd a woman of a feeble and lean child, whose head showed the 
exact form of a sugar-loaf, the eyes were oblique from upwards 
and outwards to downwards and inwards, the nose was flat, and 
had only one aperture ; this malformation being accompanied 
with hare-lip, fissure of the palate, and imperforate anus. In the 
hospital of Shitomir, Russia, a case of inborn idiotism* has been 
observed, in which the cranium was four and one-half inches in 
length, and three and three-fourth inches in breadth, and was in 
several places two thirds of an inch thick. Dr. Slmetter, of New 
York City, has seen three cases of congenital complete ossification 
of the sutures and fontanels ; the heads being hard and well 
rounded. The delivery was difficult in all of these cases, and the 
infants did not reach the end of their first year. Another case has 
been reported by Allen. f All the sutures were ossified, the cra- 
nium was like that of an adult, dense and solid, and had to be 
perforated before it could be born. 

The size and symmetry of the skull depend upon both the ad- 
vancement and seat of the ossification of the sutures, and the 
adjustment of those parts which are not ossified. For the growth 
of the fiat cranial bones which commences from the sutural sub- 
stance, ceases mostly after the ossification is consummated. Gib- 
son and Soemmering were the first to understand the importance 
of the substance of the sutures, considering it to be the matrix of 
the growth of cranial bones ; but Hyrtl was the first to show that 
pathological forms of the cranium might depend on the premature 
closure of single sutures. Fr. C. Stahl^ considers the ossification 
of the sutures to be rather the final end of the whole gradual con- 
figuration of the cranium and cerebrum. Ludwig Fick § thinks 
proper to deny positively any influence of the cranium on the cer- 
'ebrum. 

We have stated, that the growth of the flat cranial bones most- 
ly ceases after ossification of the sutures is consummated. This 
is an undoubted fact, but is nevertheless not without limitation. 



* On the state of national health and the efficiency of the civil hospitals in the empire, in the 
year 1855. St. Pctersburgh. 1856. p. 271. 

f Neio Orleans Medical News and Hospital Gazette, March, 1857. 

X Neue Beitrage zur Physiognomik und pathologischen Anatomic der idiotia endemica. 
Erlangen. 1848. — Damerowh Zeitschrift fur Psychiatric. 1854. xi. 4. 

§ Ludwig Fkk : Neue Untersuchungen iiber die Ursachen der Knochenformen. Marburg, 
1859. 



78 

For it is an old remark of Kolliker's, that after the ossification 
of. the frontal suture in children, the frontal bone always increases 
in size, particularly between the tubera. And Huschke* ar- 
rived, from very exact and numerous measurements, at this result, 
that the cranium is increasing in size up to the sixtieth year, a 
period when the sutures are perfectly closed. The cause of this 
general result is found in the fact, that the osseous substance is 
reabsorbed from the interior, but reproduced from the exterior 
periosteum. Nevertheless, it may be stated as a rule, that gener- 
ally after the ossification of the sutures and fontanels is complete, 
the brain cannot increase its volume except by forcing asunder the 
sutures, or by reabsorption of the inside of the cranium. 

The variety of forms of the cranium produced by the earlier or 
later, partial or total synostosis of all or some of the sutures, is 
very large. For discerning these various forms, R. Virchowt has 
successfully adopted a terminology, similar to the one used by 
Retzius, for discriminating the varieties of races by their skulls, 
which we reproduce, although being well aware of partial objec- 
tions made to it4 

1. Macrocephali, large heads ; general circumference of the head too large. Hy- 
drocephaly waterheads. 

2. Microcephali, small heads ; general circumference of the head too small. Nan- 
nocephali, dwarfheads. 

3. Dolichocephali, longheads. 

a. Simple dolichocephali ; synostosis of the sagital suture. 

b. Leptocephali, narrow heads ; lateral synostosis of the frontal and pariet- 

al bones. 

c. Sphenocephali, cuneated heads ; synostosis of the parietal bones, with 

elevation of the region of the large fontanel. 

d. Clinocephali, saddleheads ; synostosis of the parietal and sphenoid bones. 

4. Brachycephali, shortheade. 

a. Simple brachycephali, bigheads ; synostosis of the parietal bones with , 

the occipital bone. 

b. Plagiocephali, oblique heads ; synostosis of the frontal with one parietal 
bone. "Where a considerable adjustment takes place : Platycephali, flatheads. 

c. Oxycephali, pointed heads, sugarloaf heads ; synostosis of the lambdoid 
and squamous sutures. 

* Emit Huschke, Schddel, Hirn und Seele des Menschen und der Thiere, nach Alter, Ge- 
schlecht und Race. Jena, 1854. 

t Verhandlungen der physicalisch-medicinischen Gesellschaft zu Wilrzburg, 1851, vol. ii. 
230. — 1852, vol. iii. 247. — 1856, vol. vii. 199.— R. Vikcuow : Gesammelte Abhandlungen 
zur wissenschaftlichen Medicin. Fraukfurt, 1856, p. 891. 

\ J. Christ. Gustav Lucae, zur Architectur des Menschenschddels, nebst geometrischen Ori- 
ginalzeichnungen von Sch'ddeln normaler und abnormer Form. Frankfurt, 1857. 



79 

We have found that ossification of the sutures leads not only 
to asymmetry of the cranium, but to the gradual cessation of the 
growth of the cranial bones. The cerebral functions depend to a 
great extent upon the size and symmetry of the cranium ; in cases 
of considerable diminution and asymmetry, we are almost certain 
to find that not only the intellectual faculties, but also those of 
locomotion and sensibility are injured. Convulsions, deafness 
and dumbness, failing of the sexual instinct are known to be fre- 
quent consequences of an early and extensive synostosis of the 
sutures. Where it is limited to one side or locality, an adjust- 
ment is possible in the direction of the yielding, unossified 
parts ; in such cases the cerebral functions may be nearly or 
wholly normal. Other less favorable cases look like the one of 
osteosclerosis cranii, not long ago reported by Schutzenberger.* 
The disease lasted about four years, before the continually increas- 
ing compression of the hard, compact, and eburneated cranium, 
succeeded in effecting the death of the patient, who had endured 
all his life frequently repeated faintings, a long series of epileptic 
and tetanic attacks, abnormal irritability, mental weakness, and, 
at last, idiocy. < 

With the only exception of the macrocephalic — hydrocephalic 
— form of the cranium, there is none which has been studied with 
so much eagerness and success, as the microcephalic one, particu- 
larly in its relation to the diminution of mental faculties. Bail- 
largcrf saw, in a village of southern Switzerland, three microce- 
phalic idiots whom their mother reported to have been born with 
their skulls perfectly closed and solid. Two other children of 
hers, who were well developed, both bodily and mentally, had 
their large fontanel open for a long while after birth. Similar 
facts he learned from another woman, who was mother of one 
microcephalic idiot, and of some other children of normal develop- 
ment. Furthermore, he describes the cranium, in his possession, 
of an idiotical child, 4 years old. Its dimensions are very small 
indeed, the largest circumference not being thirty-five centimeters. 
The coronal suture had disappeared entirely ; no less so an osseous 
prominence. Only the lambdoid suture was slightly discernible. 

Similar cases have been observed by others. Vrolik,:}: of Am- 

* Archives, giniratea, 185(5. No. 8. 

t Gazette des hdjpitaux, 1856. No. 91.— Bull. deV Acad. XXI. p. 950. 954. 1856. 
\ Verhandelingen der K. Akad. der Weetenschapen, 1. Deel. Amsterdam, 1854. Schmidt's 
Jahrb., 85. 3. 



80 

sterdam, knew a,n idiotical boy of 7 years, whose cranial sutures 
had entirely disappeared. 

The skull was asymmetrical, the face appearing as it were to be 
bent from the left to the right side, the occipital portion from the 
right to the left. On the left side the fossa cerebelli was larger, 
the cavity of the hemisphere of the cerebrum smaller ; the bones 
were also thicker on the left side of the cranium, than on the 
right. The frontal bone was flat, the frontal tubera very little 
prominent ; the parietal bones high but short ; on the left parietal 
bone, and on some other parts local rarefieation of osseous sub- 
stance ; the occipital bone oblique and flat. There were no 
digitated impressions on the inside of the cranium, all the sutures 
almost completely closed. With the exception only of the mas- 
toid foramina, the apertures of the emissaria Santorini were very 
narrow, but the carotid canal was wide. The ethmoid bone was 
narrow, no juncture visible between the anterior and middle 
clinoid processes. The oval, anterior condyloid, and auditory for- 
amina were very large, the round one small. Upper jaw, nasal 
and jugular bones were remarkably developed. The hemispheres 
of the cerebrum were so much shortened, as to leave the cerebel- 
lum partly uncovered ; gyrifew and incomplete, sulci flat, olfactory 
nerves thin. In the cerebrum the right hemisphere, in the cerebel- 
lum the left one, was largest. Pons Varolii was narrow, the ob- 
longated spine disproportionately thick. The lateral ventricles 
were expanded by serum to such a degree as to leave between the 
ventricle and the coronal suture, only a thin transparent pellicle 
of what was formerly normal cerebral substance. Corpus striatum 
and thalamus were abnormally flat. 

Cruveilhier reports the case of a child 18 months old, without 
any discernible sutures. There was, besides, instead of the nor- 
mal external occipital protuberance and the semicircular line, a 
transverse, very sharp osseous prominence. The vertical diame- 
ter of the cranium was as short as one inch. There had never 
been even a vestige of intellectual faculties. 

After all, premature cranial ossification, although there may be 
many other causes of idioc} r , is deserving of every consideration. 

The normal human brain differs from the animal not only in its 
relative volume, but also in its growth. Besides, the fontanel of 
the human cranium is not found in animals, with the exception 
only of a few varieties of apes, who have, for a short time after 



81 

birth, small and rapidly ossifying fontanels. Therefore Baillar- 
ger, taking into consideration both the growth of the brain, and 
the premature ossification of the cranial sutures, thinks himself jus- 
tified in comparing microcephalic idiots to animals. Gratiolet 
did not even stop here, but asserted, in the meeting on August 
25th, 1856, of the Paris "Jlcademie des Sciences" that there is a 
direct relation between the earlier or later ossification of the 
sutures, in the different races and types of mankind, and the hight 
of their intellectual faculties. He states, as we have mentioned 
above, that the cranial sutures close later in Caucasians than in 
Negroes, and particularly, that the coronal suture ossifies early in 
Negroes, late in Caucasians. For this reason a proportionally late 
ossification of the coronal suture seems to be favorable to intellect- 
ual development. The high forehead also, of the Caucasian, and 
the low one of the Negro race are evidently depending on this 
physiological fact, although it may be stated that the synostosis of 
the sutures is not the only cause of cranial difference in the races, 
the various characters of the crania, as they are found in different 
races, being partially formed before synostosis of the sutures is 
complete.* 

A frequent result of cranial premature synostosis appears to be 
deafness and dumbness (two such cases have been reported by Vir- 
chow) and cretinism. 

Eulenberg and Marfels made a post-mortem examination in a 
case of cretinism. The cranium and brain were asymmetrical, 
gyri of the left side broader, straighter, more simply formed. 
Even more difference was shown in the chiasma, which was one- 
twelfth of an inch broader on the right side ; nerv. opt. and corp. 
striat. more developed on the right side ; the cortical substance 
remarkably thin in proportion to the medullary substance. The 
right side of the cerebellum was softer and smaller than the left. 
There was a far-spread hyperamiia around the spheno-basilar 
synostosis which was present in this case ; and which, for this 
reason, is considered by the reporters as the* result of an inflam- 
matory process, the origin of which is to be traced back to foetal 
life. 

Even more frequently than the above-mentioned abnormities has 

* E. IluschJce, itber cranio-sclerosis totalis rhachitica und verdickte Schddel i'tberhaupt, nebst 
neuen Bwbachtungen jener Krankheit. Jena, 1858. 



82 

epilepsy been observed to be a frequent consequence of preco- 
ciousness of cranial synostosis. In a great number of epileptics 
the form of the cranium is anomalous ; thus Rieken already no" 
ticed, in a man suffering from epilepsy, a lower situation, larger 
size, and malformation of all the parts of the right half of the head.* 
In proportionally few cases it is too large, hydrocephalic ; in most 
of them it is too small, and_spherical or pointed. The most import- 
ant characteristic, however, is asymmetry, the head appearing, as 
it were, compressed from a lateral, anterior or posterior direction. 
Among forty-three epileptics, recorded by Miiller, of Pforzheim,t 
the heads of thirty-nine .were asymmetrical ; in the majority of 
them there was, besides, hyperostosis of the cranium. The older 
a case of epilepsy, especially if it dates from the first years of life? 
the more the cranium will be dense and eburneated. Epilepsy 
originating at this early age, is considered to be the most critical 
and incurable, leads often to, or is complicated with idiocy, and 
shortens the duration of life.J We have been informed by Dr. 
Schilling, of this city, of the case of a girl eight years old, who 
has been suffering for some years past from epilepsy, which, led by 
anamnestical facts, he does not hesitate to trace back to premature 
synostosis of the cranial junctures ; we have ourselves been attend- 
ing for four or five months a girl of fifteen years, whose menses 
were regular and pretty copious, who has been suffering since her 
second year, once, twice, or three times every day of her life from 
epileptic fits, which we can, by every possible evidence, attribute 
to the same cause. 

Epilepsy is rare in new-born children — frequent after the first 
dentition. Hyperostosis of the cranium, particularly in cases 
dating from early childhood, seems also to prove, that too rapid 
and abundant ossification of the cranial bones, before the brain 
has obtained a sufficient growth, and the compression of the brain 
produced thereby, are among the causes of epilepsy. Every case 
of this kind is illustrated by Travers,§ who reports the case of an 
epileptic boy suffering from compression of the brain, which was 



* v. Ordefe's und v. Waltherh Archiv fur Chirurgie und Augenheilkunde. XVII. 2. 
t R. Virchow : Handbuch der speciellen Pathologie und Therapie, vol. iv. i. 268. 
% Romberg : Lehrbuch der Nervenkrankheiten, p. 697. 

§ B. Travers : A further Enquiry concerning Constitutional Irritation and the Pathology 
of the Nervous System, p. 285. 



83 

caused by a particle of the fractured cranium. There was no 
other fit, after the fractured bone had been removed. 

According to Chazeauvieilh* of sixty-six cases of epilepsy, 
eighteen occurred in the first lustrum, eleven in the second, eleven 
in the third, ten in the fourth, five in the fifth, four in the sixth, 
one in the seventh, two in the eighth, one in the ninth, two in the 
tenth, one in the twelfth : that is to say, more than twenty-seven 
per cent, occur under the first five years, and probably even be- 
tween the second and fifth year of life. This is just the period of 
infantile development, in which irregular ossification may begin 
to prove dangerous. For, as Romberg emphatically asserts, the 
orgasm of the brain, inclosed as it is in unyielding osseous walls, 
cannot but favor the transmission of remote irritations to the cor- 
pora quadrigemina and the oblongated spine, and thereby pro- 
duce irregular reflected motions. On this principle, convulsions 
are the habitual consequences of cerebral hypertrophy, which is 
frequently combined, too, with hypertrophy of the cranium. 

Every symptom, in all the objects of the foregoing exposition 
can be explained, as it were, by a relative hypertrophy of the 
brain ; that is to say, by a disproportion between the closed and 
narrow skull and the inclosed and growing brain. Such, how- 
ever, is the similarity between the symptoms of some of the most 
different cerebral diseases, that a distinct diagnosis of the patho- 
logico-anatomical alterations is not always easy, sometimes very 
difficult. Laennec,t in referring to Jadelot's remarks on the dis- 
proportion between skull and brain, has already acknowledged, 
that he sometimes made serious mistakes in the diagnosis of 
hydrocephalus internus. He confesses that in a number of cases 
he met with no water at all, but only with a remarkable flatten- 
ing of the gyri, which seems fully to prove that the brain was 
compressed, by its volume being too large and its growth too ac- 
tive ; and next, with an extraordinary firmness and elasticity of 
the cerebral substance. Next to Lsennec, in 1824, Hufeland com- 
municated to the profession his observations on cerebral hyper- 
trophy, which he, too, declared to have been often confounded 
with hydrocephalus internus. It was he who established a new 

* De Vtlpilepsie consvd&rfo dans ses Rapports avec V Alienation Mentale. Arch. G6nir. t 
1825, p. 73. 

t Journal de Medecine, Chirurgie et Pharmacie, 1806, vol. xi., p. 669. Revue Medicate, 
1828, observations pour servir Vhistoire de Vhypertrophie du cerveau. 



84 

fact met with in every such case, viz., the cerebral hernia ; that is 
to say, he showed, that in every post-mortem examination in these 
cases, the compressed, elastic brain springs forth through the 
incisions made into the membranes. He is, however, always 
speaking of an abnormally large brain within a normal skull, of real 
cerebral hypertrophy ; and identical with his cases, are those re- 
ported by Scoutetten, Meriadec, Laennec, Burnet, Papavoine, 
Cathcart Lees, and Barthez and Rilliet. 

Some years ago, we had occasion to observe three unmistakable 
cases, the reverse of those treated of above — that is, cases of an 
originally normal brain in an abnormal cranium, this having re- 
mained too narrow in consequence of premature synostosis of the fon- 
tanel and sutures. This narrowness, however, was the only 
anomaly ; for the process of ossification would not have been 
irregular at all, if it had ended some months later ; there was no 
constitutional disease of any kind, not even a sign of hyperostosis, 
or of preceding inflammation. The three patients, who came 
under my observation in August. 1851, in the fall of 1855, and in 
August, 1856, were children — two ten, and one eleven months of 
age ; the first one a male, the other two females. All of them 
were well developed, had been robust and apparently always healthy. 
The third one was said to have, in the last months preceding her 
death, from time to time, cried vehemently and suddenly, without 
any manifest cause. In neither of these cases was it possible to 
perceive weakness of intellect, apathy, somnolence, and feebleness 
of the extremities, all of which symptoms Cathcart Lees considers 
as indispensable signs of genuine hypertrophy of the brain. In 
the first case, it was stated that the child lost his habitual bright- 
ness and liveliness about a fortnight before the symptoms became 
severe ; in the other cases, this failing could be observed but a 
day or two before symptoms of depression of the brain were 
visible. The children grew sleepy, almost soporous, the pupils 
enlarged ; vomiting soon followed. From time to time, they ex- 
hibited, especially the third patient, light intermediate signs of 
irritation. Contractions of the extremities came next, and, in 
short, all the graver signs of depression of the brain. The sopor- 
ousness increased so as to become complete unconsciousness, every 
sensual function being totally paralyzed ; and, at last, death 
ensued with clonic convulsions. 

The picture we have given of this disease is the almost exact 



85 

likeness of the last stage of the inflammatory and exudatory diseases 
of the brain and its membranes in general. Its distinct diagnosis is, 
therefore, sometimes impossible, and always difficult. The pres- 
ent state alone of a patient, who lies prostrate, with all the symp- 
toms of depressed brain, will not enable a medical man to get a 
clue to what has preceded. Sometimes he will obtain anamnes- 
tical facts, the best of which is, at all events, the knowledge of tlie 
condition of the large fontanel and cranial junctures. In this man- 
ner, we were enabled to make an exact diagnosis in the cases of our 
last two patients. We found that in the children, ten and eleven 
months old, the large fontanel was entirely closed, and no pul-se 
could be felt through it. In the last case, the parents, without 
any suggestive questions of ours, and only induced to do so by our 
examination of the fontanel, told us, that the fontanel of another 
child of theirs, who had died two years before, at the same age, 
and under the same symptoms, was also closed long before death. 

In the first and third cases we were allowed to make a post-mor- 
tem examination. The result was alike in both of them. There 
was nowhere a pathological alteration to be found, except the abnor- 
mal solidity of the cranium and the following state : The cavity of 
the cranium was completely and compactly filled up by the brain ; 
the membranes were pale. No signs of inflammation or only hy- 
pertonia. The sinus narrow ; gyri flattened ; the substance of the 
brain dense, elastic, difficult to cut ; of an apparently considerable 
specific weight. The gray substance was whitish ; fluid in the 
ventricles not remarkable in quantity. There was no disproportion 
between the different parts of the brain, a symptom, which never 
fails in genuine cases of cerebral hypertrophy ; this being but an 
increase of the white substance, while the grey one remains un- 
altered, and affecting neither the middle part of the brain nor the 
cerebellum, while the pressure of the ' unyielding cranium, when 
no adjustment has taken place, will sometimes, but not always, 
operate in every direction, and affect every part of the brain, 
which may be sound in every other respect. 

The abnormal state of the cranium and the brain which we treat 
of, is almost overlooked by the best authors on diseases of chil- 
dren, Rilliet and Barthez. There is only a short notice in their 
book relating to premature closure of the cranium as being a cause 
of induration of the brain, and they seem to be so little aware of 
the intrinsic difference between induration of the brain and its 



86 

hypertrophy, that they treat of both of them in the same short 
chapter (the fifth of their first volume). So does Churchill, 1. c. p. 
178. Even Forster* one of the most excellent authors on path- 
ological anatomy, scarcely mentions our subject, so that in treat- 
ing of " induration of the brain," he says : " Increased consistency 
of the whole brain, or total sclerosis, is a normal occurrence in 
old age, and of the same frequency, but less importance, in intoxi- 
cation by lead, in typhus, cholera, puerperal peritonitis, scarlatina. 
Only in intoxication by lead, where induration is combined with 
atrophy, it reaches such a hight as to affect seriously the cere- 
bral functions. In other cases, the increased consistency of the 
cerebral substance is of some interest only when found in post- 
mortem examinations, and is usually produced by copious exuda- 
tions, leaving the brain deprived of its parenchymatous serum. 
High degrees of total sclerosis are met with only in atrophy of 
the brain. 

Cases of sclerosis of the brain are met with, sometimes, in re- 
ports on post-mortem examinations ; cases, too, of premature 
closure of the cranial junctures have been communicated to the 
profession, but in very few of them has an attempt been made to 
elucidate the evident relation between these two anomalies. 

F. Webert reports a case of sclerosis of a part of the cerebrum, 
which we are hardly entitled to consider as belonging to the class 
of cases forming the subject of our treatise. The author is not 
aware of the importance of the early or late closure of the cranial 
junctures, but thinks it a remarkable fact, that sometimes small, 
puny children, with small heads, exhibit cranial bones reaching a 
high degree of osseous development, while in other cases, in large, 
strongly built children the cranial bone3 were thin and easily cut 
with a pair of scissors. Thus, in the report of a post-mortem ex- 
amination of a child, who died at the age of seven months, after 
having suffered from convulsions for half a year, he entirely omits 
to state the condition of the fontanel or cranial sutures. The case 
was that of sclerosis of the right hemisphere, which felt to the 
knife like cartilage; particularly its gray substance was dense 
and hard even where the white substance showed the average soft- 



* A. Forster, Ilandbuch der pathologischen Anatomic, ii. p. 427. 

t F. Weber, Beilraege Zur 'Pathologischen Anatomie der Neugebornen, Kiel, 1851, i. p. 31. 
46. 



87 

ness of a normal cerebrum. Nor was the structure of the parietal 
bones like that usually found where premature ossification of the 
sutures has taken place ; the bones showing rather a soft hyper- 
asmic thickening than a solid hyperostotic condition. 

Of more value for our purpose is the case of " sclerosis cerebri " 
reported by Stiebel, Jun.* It is the case of a"girl, paralyzed in her 
left side after a severe attack of convulsions occurring in her third 
year. About that time the general health of the child does not 
seem to have been influenced by the disease, which made progress 
during the next half-year to such an extent, that the left half of 
the body being paralyzed, the right was affected with clonical 
spasms, and psychical action considerably diminished. At the 
same time contractures were observed on the side affected with 
spasms ; but notwithstanding all this, the bodily development, the 
embonpoint, had not been affected. No sooner than a year after- 
wards, the child was emaciated, the other symptoms remaining 
the same throughout the whole time, until the child died at the 
age of more than five years. The post-mortem examination of the 
cranium and cerebrum gave the following results : The skull 
was very thick, from one-sixth to one-third of an inch, like that 
of adults ; the dura matter thickened to at least as much as twice 
its normal size, firmly adhering to the skull, and, on the right side, 
to the brain. The bloodvessels of the arachnoid membrane were 
much injected with blood, and there was a jelly-like exudation all 
over the surface of the cerebrum. The left hemisphere was of nor- 
mal consistency and pretty well filled with blood ; its gray and 
white substances were very distinctly separated from each other. 
The left ventricle contained a large amount of serum, foramen 
Monroi was dilated. The right ventricle was' somewhat enlarged ; 
its walls were normal. The right cerebrum, with the exception 
of the anterior lobe, and the inner part of the middle lobe, was un- 
altered in its shape, but of a dense, hard, and nearly cartilagin- 
ous consistency ; it was of a whitish yellow color and could be 
cut into very thin, blueish, transparent slices. The microscopical 
examination exhibited a proportionately small number of cerebral 
ganglia, very few varicose cerebral fibres, but a large number of 
amorphous masses interspersed with some fat globules. In the 
gray substance the capillary system was developed to an unusual 
extent. 

* Journal fur Kinderkrankheiten, 1857, Jan. and Feb., p. 76. 



88 

W. PIughes Willshire* reports the case of a sickly, puny 
scrofulous girl, of a year and five months, who was said to have 
fallen sometime ago and hurt her head. The fontanels were closed, 
the eyes squinting, and the tarsal margins somewhat inflamed. 
The child could not lift her head, the dorsal muscles appeared to 
be somewhat opisthotonic, and the upper part of the body was 
drawn backwards. Such was the state from the 17th of January 
to the 27th of February, when the child fell sick with variola ; 
convulsions, stupor, and pulmonary oedema soon ensued, and a 
speedy death followed. The post-mortem examination gave the 
following results : Cranium was completely ossified, dura mater 
firmly adhering to the bones, the gyri were narrow, pressed into 
each other, sulci partly obliterated. The meningeal bloodvessels 
were overfull of blood, on some spots there was some milky exu- 
dation along the course of the ^ssels. Brain was solid to the 
touch ; it was hard and heavy after being taken from the skull ; 
when incised, it appeared condensed, compressed ; most so the 
white substance. Most solid were the thalami optici, much less 
so the cerebellum. In the ventricles there was some serum, and a 
little exudation on the basis. 

One very good observation was published, some time ago, by 
Prof. Mau timer, of Vienna.t 

Case. — Mary F., 3 J years old, is said to have suffered, 1^ years 
ago, from convulsions caused by a fall on the occiput. She has 
been sickly ever since. When taken to the hospital, she exhibited 
the following state and symptoms : The child is emaciated, feeble ; 
hair of a light brown color, cranium remarkably small and hard, 
particularly so in the occipital region ; the countenance has a suf- 
fering expression ; lips and tongue are red. The child sucks her 
thumb continually. The abdomen is concave ; the lower extremi- 
ties are drawn to the abdomen ; pulse thin and much accelerated ; 
sleep restless. Evacuations dry, rare. 

Treatment. — Four leeches on the mastoid region. Carb. Magn. 
to facilitate defecation. 

Two days later, June 11th. — The child moans frequently ; sleeps 
very little. No evacuation. Sulph. magn. 3i., aq. giii. 

The following day one evacuation. Constipation again to the 

* London Lancet, Oct., 1853. 

t Oeslerreichische Zeitschrift fi'ir Kinderheilkundc, Sept., 1857, p. 561, sclerosis cerebri ex 
microcephalia. 



89 

16th, when jalap 3ss. was required to open the bowels. No 
change in the other symptoms, only the emaciation and feebleness 
of the patient are increasing. Three convulsive attacks, of only 
two or three minutes each, occurred during the night. 

July 2d. — The child continues to moan and whine. Hands 
cyanotic ; abdomen hard, somewhat inflated ; skin dry. One con- 
vulsive attack in the morning. Sucks her thumb. Constipation 
of the bowels. Carb. magn. gr. x., aq. §ii. 

July 5th. — The child is very low ; has fallen off considerably. 

July 14th. — Since yesterday ten thin, greenish-yellow passages, 
mixed with mucus. Hands cold. Dec. salep §ii., pulv. r. ip. gr. 
x., syr. simpl. 3ii. 

July 18th. — Collapse increasing. Diarrhoea but little better. 
Pulv. Dov. 

The child grew worse from day to day, emaciation going on in 
rapid progression ; appetite lost ; eyes hollow ; face and extremi- 
ties cyanotic ; temperature of the skin low ; passages not so nu- 
merous, but thin and mucus. After some days of constant sopor, 
the patient died on the 25th of July. 

Post-mortem examination. — The corpse is very much emaciated ; 
abdomen discolored, greenish, concave ; the extremities are flexi- 
ble. The cranium is of unusual compactness and smallness. The 
integuments being removed, the distance from the root of the nose 
to the external occipital protuberance is twenty-two centimetres, 
from one ear to the other 23|. The circumference of the cranium 
is forty-two centimetres. While the cranium is getting opened, a 
great deal of serum is escaping. The membrane is thick, adheres 
firmly to the cranium, and can only with some difficulty be removed. 
The fontanels have disappeared entirely, the sutures are found to have 
been ossified long ago. The left hemisphere is of very small size • 
its gyri are hard, of a dirty yellow color, showing signs of atrophy. 
Between the layers of the pia mater are four ounces of a thin dark 
serum, mixed with blood. The pia mater of the right hemisphere 
is slightly injected with blood. The cerebral substance is pretty 
dense. The right lateral ventricle is not dilated. All the nerves 
originating in the brain are of a considerable toughness, as well as 
the flattened gyri ; pons and cerebellum are normal ; medulla ob- 
longata very hard ; some fibrine coagulated in the longitudinal 
sinus. The cranium is as thick as one centimetre about the squa- 
6 



90 



mous part of the temporal bone. Its longitudinal diameter is 15 
centimetres; the transversal 11^. 

A very interesting and instructive case, which has been our for- 
tune to meet with, is the following : 

George Z., of Forsyth street, eleven months old, a robust child, 
was not known to have ever been sick. He became restless and 
feverish on the first of November, 1857, with augmented tempera- 
ture, of the head and slight vomiting. His parents, believing him 
to suffer from " dyspepsia," administered an emetic. On the fol- 
lowing day he spontaneously vomited twice, the general state re- 
maining as above-mentioned. Bowels open and water passed freely. 
We were requested to see the patient at seven o'clock, P. M. 

Present state. — Slight clonic convulsions of the muscles of the 
face and superior extremities ; forty breathings in a minute, pretty 
regular ; pulse contracted, 140 ; pupils somewhat dilated, react on 
the influence of sudden light, but are floating for a while after- 
ward and dilate again ; conjunctiva sclerotica^ slightly injected 
with blood ; occiput abnormally warm ; hands and feet of normal 
temperature. The child in general was well developed, the head 
somewhat large ; six teeth cut some months ago ; the gum is 
swollen. The sutures and the large fontanel perfectly closed, and 
have been so, as far as I could learn from the very intelligent re- 
latives, for at least three months. 

Diagnosis. — Cerebral sclerosis from mechanical compression of 
the brain, caused by premature closure of the cranial junctures, 
increased by cerebral hyperemia consequent on dentition. 

Prognosis. — Probably fatal f the patient may recover from this 
attack, but only to die by a future one, or at best will become 
idiotic. 

Treatment. — Calom., jalap, aa. gr. j., to be taken every hour ; 
head to be kept under ice. 

The convulsive attack lasted for three hours, the muscles of the 
inferior extremities becoming also affected; there was only one 
short intermission after copious vomiting. Patient vomited once 
more at eleven o'clock, P. M. At midnight, fifty-two breathings 
in a. minute, somewhat irregular ; pulse as before, 172. Tempera- 
ture of the occiput even higher than before ; conjunctiva sclero- 
ticae more injected. The child no longer fully unconscious. 

Nov. 3d, 8J o'clock, A. M. — Pulse contracted, somewhat irregu- 



91 

lar, 144 ; fifty breathings, interrupted by sighing. The child is 
prostrate, spiritless, with an expression of pain about the corru- 
gatores of the eyebrows. The right eye more injected than the left 
one ; no more convulsions ; bowels have been open three times ; 
water has been passed several times. Patient vomited once, not 
long after midnight ; has taken the. breast four times, and is con- 
stantly looking aroun-d for water. 

Four o'clock, P. M. — Took the breast and drank several times ; 
vomited four times ; left hand is constantly kept on the parietal 
bone ; pulse as before, 144 ; respiration sometimes sighing, thirty- 
eight ; eyes hollow, considerably injected with blood ; occiput ab- 
normally warm ; feet cool, hands cold. 

Treatment the same. Hot poultices of mustard and linseed on 
feet and legs. 

Ten o'clock, P. M. — Vomited twice, each time after drinking ; 
took the breast several times ; had no convulsions, but shook his 
limbs under the bed-clothes, from time to time, as if from impa- 
tience. Respiration, as above, 35 ; pulse, 130, somewhat irregu- 
lar ; body warm all over, with the exception of the nose, which 
was cool. Feels every slight touch ; screams abruptly and vio- 
lently when his eyes are forced open. During sleep, the eyelids 
half opened ; pupils small. After being awakened from his heavy 
sleep, his pupils are a little dilated ; contract by the action of 
light, but afterwards float, and dilate again. 

Treatment. — Calom. gr. j., extr. hyosc. gr. £ every hour. Ice 
continued. 

Nov. 4th, half-past eight o'clock, A. M. — Pulse and respiration 
as yesterday : 144, 54. No change at all, with the exception of 
the patient's vomiting no longer ; he is alternately either awake 
or unconscious, or in a kind of heavy sleep ; had two evacuations 
of the bowels, passed water freely. Feet cool. 

Six o'clock, P. M. — No change ; no convulsions ; no vomiting. 

Nitri. Sod. 3ij. extr. hyosc. gr. iiss. inf. digit, (egr. xij.) giij. a 
teaspoonful to be taken every two hours. Ungt. hydrarg. for ex- 
ternal use. 

The flexions and extensions of the right superior extremity kept 
on and increased, the child grew more restless, threw his head from 
one side to the other, respired more frequently and irregularly. 
Nevertheless, about one o'clock, A. M., he took the breast, but 



92 

only for a minute. The increased irritation was soon followed by 
unconciousness and sopor, which lasted for about an hour. With 
the usual symptoms, oedematous rhonchi, etc., death ensued at half- 
past two o'clock, A. M., November 6. 

Post-mortem examination, four o'clock, P. M., thirteen and a half 
hours after death. Front side of the corpse pale, back side red 
and brown, by hypostasis ; conjunctiva sclerotica not injected 
with blood. Galea aponeurotica pale throughout, except on the 
occiput, where it was suffused with blood, more so than could be 
explained by hypostasis alone. All the integuments being re- 
moved, about fifteen white and unusually dense insular spots, of a 
diameter of from a twelfth to three-quarters of an inch, become 
visible on the frontal and parietal bones. Cranium not abnor- 
mally thick, occipital bone even rather thin ; besides, it is hyper- 
asinic, and shows on its inside digitated impressions of such an ex- 
tent as are met with only in adults. The insular spots, being the 
places of increased local ossification, are just as manifest inside as 
outside. Of the frontal suture there is no sign. Between the 
frontal and the parietal bones, there is no interval, the large fon- 
tanel having totally disappeared. Where the large fontanel ought 
to be, the coronal and sagittal sutures are not wholly ossified, but 
they cannot be disjointed by any means. Ossification is perfect 
everywhere else. 

The dura mater cannot be torn from the cranium; the mem- 
brane is of such a thickness and adheres so firmly to the cranium, 
that it has to be separated from the bone by means of the scalpel. 
The sinuses are full of blood ; so are all the blood-vessels of the 
pia-mater, particularly on the cerebellum ; nowhere extravasated 
blood or any pathologico-anatomical alteration, such as tubercles, 
exudations, etc. 

The brain large, heavy, solid, proportionally developed in its 
several parts ; gyri numerous and solid, some of them evidently 
flat, particularly so on the superior surface of the hemispheres. 
The gray substance is less hard than the white, but nevertheless is 
tough and elastic. This is found to be throughout the condition 
of the cerebral substance. When it is laid open by long incisions, 
no blood is seen, except on pressure. Ventricles narrow, contain 
no serum. Pons Varolii and medulla oblongata are most solid and 
dense ; they are difficult to cut. The cerebral substance, after 



93 

having been outside the cranium and handled and turned for at 
least an hour, remains pretty hard and solid. 

Although the diagnosis, in the foregoing case, was clear and 
fully proved to be correct by the post-mortem examination, there 
are some interesting facts apparently contradictory. After the 
first attack of convulsions, no other occurred for three days, al- 
most up to the hour of death ; constipation and anuria, so com. 
mon in cerebral diseases, were also absent. 

Between our last case and the one of Prof. Mau timer, there is 
one important similarity. The thickness and firm adhesion of the 
dura mater along the sutures and in the region of the large fonta- 
nel, in both cases, seem to prove, that a chronic congestive or in- 
flammatory process was both the cause of the pathological altera- 
tion of the membrane itself, and of the abnormal deposition of 
phosphates and carbonates in the flat cranial bones. No such 
alteration of the membrane was found in our former post-mortem 
examinations, at least to no remarkable degree. This difference is 
strikingly confirmed by the condition of the bloodvessels. In 
some cases, they were filled with blood, in other ones the membranes 
were pale and bloodless. 

In looking over the series of cases and observations referred to, 
another highly interesting fact will strike us. We have reported 
the case of a child whose brother died at the same age, with the 
same symptoms, the fontanel being closed and the sutures perfect. 
Baillarger, too, reports the cases of three microcephalic idiots in 
one family. Nothing of the kind however, occurred in our last 
case ; the boy had sisters — the oldest one nine, the youngest one 
three years old — the heads of all of whom are well developed, and 
even large. The youngest girl is reported to have been remark- 
able for the pulsations of the arteries being for a long period visi- 
ble through the integuments of the large fontanel. Therefore, in 
some cases of premature closure of the fontanel and the cranial junc- 
tures, an hereditary or family influence seems to be absent, while in 
other ones it cannot be denied. 

We were so fortunate as to assist Dr. J. Kammerer at the post- 
mortem examination of a man, thirty-six years old, who died from 
sclerosis cerebri. The facts resulting from this examination, Dr. 
Kammerer, who attended the deceased for some years, kindly 
allowed us to publish. We feel bound to do so, because this case is 
most apt to illustrate the subject of this essay, and because, as one 



94 

of our best authorities on diseases of the brain, Prof. Leubuscher, 
asserts cases of genuine sclerosis cerebri are exceedingly rare ; so 
much so, that the two cases diagnosed, dissected, and published by 
Prof. Frerichs * of Breslau, and the twelve other cases of sclero- 
sis of the brain or spine, they being cases only of partial, even 
merely local sclerosis, collected by Dr. Valentiner,f are the 
largest number known. It may be stated, that only in one of the 
12 cases which occurred in a man of 53 years of age, the cranial 
bones were found to be hypertrophied, and the meninges hyperae- 
mic and somewhat infiltrated. In this single case both halves 
were equally affected.:}: The short, but complete history of the 
case, communicated to us by Dr. Kammerer, is as follows : 

Case. — Deceased, a tailor, is said to have been always healthy. 
Only two years ago his countenance began to show a cachectic 
color ; in the epigastric region, a frequent soreness was complained 
of, which used to be complicated with or followed by vomiting, 
and the patient grew morose, taciturn, peevish. About the same 
time, or shortly after, a creeping pain was felt, sometimes in the 
hands and fingers, sometimes in the feet and toes, which changed 
very often, and used to alternate, as to its seat, and thereby in- 
duced the patient to consider it as rheumatic. His physician, 
however, was soon led to attribute these symptoms in the peri- 
pheric nerves to a cerebral origin, especially when slight and oc- 
casional signs of paresis became visible. Four or five months ago, 
the patient had an attack of syncope, total loss of the mental, sen- 
sory, and motory functions coming on suddenly. After this at- 
tack, he was sick for about five or six weeks, the main symptoms 
being a small and feverish pulse, and all the cerebral symptoms of 
typhoid fever, but no typhous alterations at all in the abdominal 
organs, and no trace of critical secretions. He never felt well 
afterwards ; nearly every week an attack of sudden syncope oc- 
curred, similar to the one mentioned above, after which the patient 
used to feel as usual. But the paretic symptoms in the extremities 
increased, the interval between the attacks grew shorter, and they 
were preceded by a violent headache, especially in the occiput. 
In the last weeks preceding death the attacks occurred almost 
daily, even sometimes every day, and they were preceded by the 



* Batter'* Archiv. x. 334. f Deutsche Klinik, 1856, No. 14, 15, 16. 
XHirsch^ein Fall von sclerosis cerebri. Prager Yierleljahrschri/t, 1855. -iii- 124. 



95 

most intolerable headache, which forced the patient to the most 
heartrending outcries, and was mitigated by nothing except a 
close and hard pressure on all sides of the head at once ; they 
were followed by copious sweats. In the last week of life, the pa- 
tient was scarcely able to lie down ; if he did he was sure to feel 
worse ; and he walked about his room all night. There were 
from eight to twelve attacks every day, of the same kind, as de- 
scribed above, the sweat being followed by a vehement shaking 
and chilliness. In one of these attacks the patient died. 

Post-mortem Examination, Dec. 9th, seventeen hours after death. 
Galea aponeurotica pale, bloodless ; cranium dense, particularly 
so the frontal and parietal bones. Both of them are very con- 
cave, extending very far, the one forwards, the other backwards. 
The region of the large fontanel, where the coronal and sagittal 
sutures meet, depressed ; the sutures are visible only at this meet- 
ing pome ; everywhere else they have entirely disappeared. The 
form of the cranium narrow and long (dolichocephalus, Virchow), 
diploe very much developed, imprmsiones digitatce very deep and 
. large, particularly so on the inside of the os frontis and the lower 
part of the os occipitis. The cranial impressions of the sinus, sul- 
ci venosi, uncommonly deep. Foramina emisaria are not found 
at all. The margins of the impressiones digitatas, the juga cere- 
bralia, uncommonly sharp-pointed, particularly so on the basis 
cranii. Sella turcica of an extraordinary size, and with sharp 
margins. The whole inside of the cranium and the dura mater 
bloodless ; less so the arachnoidea, without being, however, hy- 
perwmic The brain stiff, tough, hard ; gyri hard, extremely flat 
all over the cerebral surface ; the inner and upper edge of both 
hemispheres very sharp, their inner surface very flat and hard. 
The gray and white substances contain very little blood. The 
white substance looks discolored, showing a dirty grayish tint. 
Thin slices cut from the hemispheres are tough, may be suspended 
by one end without breaking or even lengthening ; the commis- 
sures prove hard and tough. The lateral ventricles very narrow, 
without any serum ; the third and fourth ventricles normal but 
narrow. The brain throughout of the same density and tough- 
ness as its surface ; pons Varolii and medulla oblongata even 
more so. No disproportion, as to size, between the gray and 
white substances. 



96 

This is, undoubtedly, an evident and very instructive case of 
sclerosis cerebri. The history of the deceased's cranium and cere- 
brum, as may be concluded from the results of this post-mortem 
examination, is briefly this : The abnormal state of the cranium 
has been the first false step in the general development, the large 
fontanel and the cranial junctures closing too early. This is 
proved to be a fact by the depression of the upper frontal and 
parietal region, by the adjustment which has evidently taken place 
in the frontal and occipital directions, and by the dolichocephalic 
shape of the cranium. From this time, that is from the third or 
fourth quarter of the first year of life, dates the disproportion ^be- 
tween skull and brain. It is probable that deceased, when a 
child, was so fortunate as to escape difficult dentition, and severe 
symptoms of irritation produced thereby ; if he had not been so, 
there is a great probability that he would have died in early 
childhood. Deceased is said to have been intelligent when at- 
tending school. This is not uncommon in cases where the above- 
mentioned disproportion advances slowly, and has not been com- 
plicated with irritative symptoms. As long as life continued there 
was a constant antagonism between cranium and cerebrum. It is* 
not improbable also, that in the last years of life renewed deposi- 
tions of calcareous matter have taken place, more so, probably, on 
the basis, than on any other part of the cranium. The frequent 
attacks to which the patient was subjected, exhausted, at length, 
the power of resistance, which is limited as well in the nervous, 
as in every other system of the organism. 

Real hypertrophy of the cerebral substance is out of the question. 
We have remarked above, that cerebral hypertrophy affects but 
the white substance, not the gray, and the large hemispheres only, 
not the cerebellum, and cannot but produce a disproportion be- 
tween the two. No such disproportion exists in our case. Be- 
sides, the shape of the cranium and the other facts alluded to are 
against such an assumption. 

After the foregoing expositions, it appears that the prognosis of 
the kind of cerebral sclerosis described is highly unfavorable 

According to the present symptoms in each case, whether a dis- 
tinct and perfect diagnosis be made or not, either a stimulant or 
an antiphlogistic treatment will seem to be indicated. The for- 
mer will aggravate the condition of the patient in every case, which 
is combined with congestion of the brain or its membranes, while 



97 

theoretically it should be adopted only where the main symptoms 
are those of perfect depression. The debilitating course of treat- 
ment may be able, at once with the diminution of the dimensions 
of the body in general, to remove, for a while, the disproportion 
between the brain and the cranium. Taken theoretically, all this 
is right and promising of success. But we cannot continue to de- 
bilitate without killing the patient by exhaustion or by menin- 
geal exudation, which so very frequently is the result of general 
and continued inanition. 

Finally, we wish to state emphatically that we do not mean to 
assert that every child whose fontanel is ossified prematurely, must 
and will fall sick and perish with cerebral symptoms at an early 
age. For the premature ossification of the fontanel and sutures 
need not of itself absolutely and always produce congestion of the 
brain or its membranes, which often becomes the occasional and 
last cause of death. But what I assert and wish to be understood 
to say is this, that every child, whose fontanel and cranial junc- 
tures have been prematurely closed, and who falls sick with symp- 
toms of cerebral irritation or depression, is predestined to certain 
death. We do not know if such has been the opinion of Condie* 
who has only a few remarks on our subject, stating that " when 
the growth of the cranium ceases, while that of the brain continues, 
the morbid phenomena resulting from the compression of the brain, 
which invariably results, may certainly be, to a great extent, abat- 
ed, the comfort of the patient increased, and life prolonged by a 
proper hygienic course of treatment — but all hopes of effecting a 
cure must be abandoned." 

In giving, therefore, the preceding exposition, we have been 
well aware of our unability to advance, in the least, therapeutics ; 
our only desire was to call the attention of the medical practi- 
tioner to a subject of the highest etiological, diagnostic, and prog- 
nostic interest. 

Hitherto, we have taken into consideration only such cases as 
have exhibited the fullest extent of their morbid disposition, in 
consequence of their complete morbid development. One case, 
however, of any disease, never appears exactly like the other, the 
peculiarities of each individual being as marked in disease as in 
health. Thus, in one case, fontanels and sutures may be equally 

* F. D. Condie : A Practical Treatise on the Diseases of Children. Fourth ed., 1854, 
p. 388. 



98 

and firmly closed, the cranium equally hard in all its parts, the 
brain under equal pressure in all directions ; in another case, the 
sutures will appear ossified or ossifying, but the large fontanel 
will be found open, perhaps pulsating ; nevertheless the pressure 
on the cerebral substance will be of nearly equal severity, because 
the fontanel alone offers the compressed brain no opportunity to 
escape the surrounding wall. 

It is but proper that a number of cases should be observed, in 
which the process of ossification has not run its full course and 
secondary sclerosis of the cerebral substance has not been fully 
developed. We are not always gratified, naturally, with the ob- 
servations of genuine interesting cases, for death often occurs 
from a trivial and apparently uninteresting cause. A child will 
sometimes exhibit for months the symptoms of the approaching 
full development of the morbid cranial condition, without our 
being able, while relieving it for a short time, to cure its dis- 
ease. Such children are usually well-developed, both mentally 
and bodily, they are fleshy and lively, but sometimes for a 
short period appear puffed in the face, and their eyes are too 
brilliant. Their heads are generally warm to the touch, some- 
times hot, particularly so the occiput ; it feels harder and 
heavier than it normally does, and is moved to and fro on the 
pillow, while the child is in a supine position ; there is always 
a relief visible, after the child has been raised, and held in an 
upright position, and some cold application made to the head. 
The child is restless sometimes for weeks or months, without 
any visible cause, particularly at night ; congestion of the head 
will sometimes manifest itself as a general flushing of the face, 
sometimes in single red spots of half an inch or an inch in 
diameter, dispersed on face and forehead, and disappearing as 
quickly as they spring up, and showing themselves again unex* 
pectedly, for a few minutes. In a boy of five months, who has 
been under our care for some time, this symptom is remark- 
ably developed, the child showing these red marks, especial- 
ly nights, together with other symptoms of congestion of the 
brain, restlessness, high temperature of the head, and sometimes 
drowsiness. The very best symptom, and of the greatest value 
for differential diagnosis, is found on the examination of the 
outside of the cranium. Besides the points alluded to above> 
the sutures will be found to have fully or nearly disappeared, the 



99 

fontanel diminished in size, and the cranium in a state of hyper- 
aemic sensibility and warmth ; hyperemia of the cranium appearing 
as well in company with hyperostotic development, as with rachit- 
ical mollification of the cranium (craniotabes). 

Wherever this general state is found, we must have the greatest 
apprehensions of the future safety of our patient. The mal- 
development will be found as impossible to stop or improve, as to 
reduce the amount of phosphate of lime, to further its excretion, 
to enlarge the calibre of the cerebral and cranial veins, to dimin- 
ish the size of the arteries, to remove, in short, all the possible 
causes of too rapid ossification. Leeches, cold, calomel, mustard, 
and a good many other remedies, antiphlogistics, resolvents, re- 
frigerants, antiplastics, derivatives, should "be resorted to cau- 
tiously, rationally, repeatedly. They are followed by good 
results. But the majority of such children will die. Only such 
children may be saved as will escape for the first years of life the 
common diseases of infancy and childhood, inflammations, ex- 
anthems, fevers. And of such children, again, the majority will 
consist of microcephali, blockheads, idiots, epileptics. 

Every febrile disease in childhood tends to produce nervous 
symptoms. Hyperaemia of the brain and its membranes, and con- 
vulsions, being well known to follow many instances of local in- 
flammatory diseases in other organs. Wherever, then, cranial 
and cerebral troubles have been greatest before, they may be ex- 
pected to be fostered and increased by every febrile attack or dis- 
ease invading the organism. In cases of a slight commencement 
of cranial ossification, where the single bones of the cranium are 
not too firmly attached to each other, febrile attacks may be less 
injurious, although every one, while bringing about congestion, 
will bring new materials to the completion of the unfortunate 
Osseous hyper-development. Wherever the ossification of the 
suture and fontanels is in an advanced stage of development, one 
single attack of fever, or of any inflammatory disease, even for a 
day, may produce congestion to the brain and its membranes, in a 
sufficient degree to cause deatli by hyperemia and pressure. 

We were called to 239 Broome Street, on February 17th, 1858, 
to see a boy four and one-half months old, who was said to have 
had a slight cough for some days, and had grown worse the last 
night. Status prcesens at four, P. M. : child not very robust, but 
well-developed ; head appears to be somewhat small in proportion 



100 

to the body. The main symptom is a considerable dyspnoea, 
respir. 58, pulse 130, nostrils move up and down, thorax but 
slightly, breathing seeming to be painful. Sensorium clear, head 
hot, face pale, on the forehead some small red spots going and 
coming from time to time. No pulse can be felt through the 
large fontanel, all the sutures are ossified. Anscultation yields 
bronchial rhonchi, equally over the whole thorax, percussion gives 
no result. The bronchitis present would of itself give no bad 
prognosis, but the peculiar configuration of the head, the prema- 
ture ossification of the sutures and fontanels, made the prognosis 
very unfavorable. The parents were told from the beginning, 
that the case was likely to end unsuccessfully. 

18th, Nine, P. M. — Resp. 48, pulse 140, Dyspnoea not so great 
as yesterday. Bronchial sounds as above ; percussion dull 
over the lower lobe of left lung. Sensorium not free. The 
child somnolent from time to time, sighing ; the face pale, 
pupils react but slowly, and will float a little after having 
been suddenly exposed to light. Temperature of the head little 
higher than normal. Slight contractions in the thumb and fingers 
of both hands, elbow a little bent, angles of the mouth sometimes 
undergo slight involuntary motions. 

Six, P. M. — Resp. 40, difficult, loud, pulse 154. (Edematous 
rhonchi in the bronchia. Hands and feet cold, nose cool, head 
hot, but pale. Eyes slowly rolling, pupils a little dilated, react 
very slowly, and very little to the light ; contractures of the 
hands stronger than before ; toes also contracted by the flexors. 
The child is not conscious, apparently moribund. 

The child had an attack of clonic convulsions in all the four 
extremities, lasting about five minutes, about eleven, P. M. After- 
wards the permanent contractions returned, the unconsciousness 
increased, coma set in, pulmonary oedema increasing. Another 
attack of convulsions occurred at four, A. M., on the 19th, and 
death five minutes afterwards. 

Post-mortem examination not permitted. 

S. F. of 100 Mott Street, a girl of nineteen months, well devel- 
oped, who had never been troubled by any kind of disease, even 
the fifteen teeth having cut without any difficulty, was seized 
with intermittent fever, having been exposed to malarial influence, 
on the 18th of April, 1858. The attack did not appear to be a very 



101 

severe one, but the child did not recover her cheerfulness for the 
whole day nor the following night ; on the next day another 
attack occurred, severer than the first, and with more dangerous 
consequences. The child remained either restless or drowsy, 
scarcely opening the eyes, the cheeks flushed, head burning. After 
the third attack of fever, on the twentieth, we were called to see 
the patient, who appeared to be in a critical situation. The child 
was drowsy, when roused, fell quickly again into what might have 
been taken to have been a sound sleep, sighed often, had a pale 
face, a hot head, contracted pupils. The cranium was hard and 
dense to the touch, no suture could be felt, no fontanel distinguish- 
ed from the surrounding bones. The size of the head, which 
was round, was not abnormal. Lungs not affected, heart healthy, 
liver not abnormal, spleen a little increased in size. Being aware 
of the importance of the osseous structure of the cranium, after 
having seen the cases referred to above, we considered the main 
symptoms to be congestion of the brain and its membranes induced 
by the intermittent fever. Thus the indications following there- 
from were, the suppression of the malarial disease, that is to say, 
the prevention of another febrile attack ; and the removal of the 
secondary congestion. A large dose of sulph. chin, was given the 
other morning before the usual time of the attack, and no particu- 
lar symptoms referable to malarial influence seemed to rise. The 
second indication was fulfilled by applying two leeches to the fore- 
head, by constantly applying cold and administering calomel. 

The history of the disease is very short indeed. Leeches and 
cold did not appear to be employed without success, for the heat 
of the head diminished. But the drowsiness, interrupted by rest- 
lessness, of the child became no less. The pupils remained con- 
tracted, the face pale ; hands and feet began to grow cold during 
the night of the 20th. Slight twitchings of the angles of the 
mouth, and slight contraction of the fingers of both hands were 
first observed in the early hours of the twenty-first. When aroused, 
the child took a spoonful of water, which was swallowed slowly 
and with difficulty. In the morning of the same day a dose of 
quinine was administered, to avoid a new check from the attack 
of intermittent fever that was expected j no symptoms of fever 
could be observed. But meanwhile the whole aspect of the case 
was somewhat changed. An attack of clonic convulsions about 
8 A. M., of the muscles of the forehead, face, neck, of the upper 



102 

and lower extremities, in short of all the voluntary muscles of the 
whole body seemed to exhaust the child rapidly and leave her in a 
worse state than before. Although the convulsions lasted for only 
ten minutes, they left the head hot and face red for more than an 
hour ; after which time the face grew deadly pale and the pupils 
began slowly to dilate. The contraction of the hands grew 
stronger, even the elbows were inflected. Contraction of the toes 
were visible and did not cease before death ensued. Hands and feet 
were cold, the drowsiness became sopor, the sopor coma. Swal- 
lowing was no longer possible, the senses were deprived of any 
action. Another slight, but general attack of clonic convul- 
sions took place at 5 P.M., symptoms of pulmonary oedema set in 
and rapidly increased, and half an hour later the child died. 

The post-mortem examination was made on the following morn- 
ing, only the head being permitted to be inspected. 

Galea aponeurotica thick and pale, cranium in its greater part 
of a livid color. All the cranial junctures firmly joined, the fonta- 
nel no longer covered by a fibrous membrane, but of osseous struc- 
ture. The anterior part of the cranium had a thickness of from 
an eighth to one-sixth of an inch, the posterior of from one-twelfth 
to one-eighth. The surface of the brain was full of blood, the 
meninges copiously injected. No extravasation nor exudation was 
found between the membranes. The gyri of the hemispheres of the 
cerebrum were flattened and approximated, the gray substance was 
thin, the white substance of a somewhat yellow tinge without 
bloody points when incised and even compressed. White substance 
hard and tough ; thin slices cut from it might be suspended with- 
out breaking. Ventricles and foramen Monroi narrow, and con- 
tained no serum. Cerebellum was softer but scarcely more filled 
with blood, except the meninges which were also injected with 
blood. Pons and medulla oblongata were of no uncommon den- 
sity. 

A boy living in No. 203 Stanton St., the fifth child of a family 
with scrofulous taint, but without any decided and severe local dis- 
ease, showed early the conformation of the head often referred to. 
The fontanel was felt not to be ossified at all, but the fibrous cov- 
ering was thick, allowed of no pulsation to be felt through it, and 
the sutures were firmly and solidly closed. The child next in age 
to this one, and sixteen months older, showed the reverse of era- 



103 

nial development, the head being large in size, and the sutures 
and fontanels open up to an advanced age, as is commonly found 
in rhachitic children. Our patient, up to nine months of age, had 
never been sick except from slight intestinal and bronchial ca- 
tarrhs. When nine months of age he showed symptoms of intes- 
tinal catarrh, in a severe form, which was not cared for ; as he 
had no medical attendance. Bronchitis supervened after a week 
and lasted for six days, during which period the child had medi- 
cal care and recovered, but was much exhausted. During all this 
time his mental faculties did not seem to be much affected. The 
bronchial symptoms had scarcely disappeared, and convalescence 
was apparently established, when the child again showed symp- 
toms of a severe gastro-intestinal catarrh, vomiting and diarrhoea 
suddenly arising again and exhausting the little patient complete- 
ly. One single fit of general clonic convulsions closed the scene 
on the last day of July. The post-mortem examination gave some 
very instructive results, the principal ones of which are given in 
the following : The cranium was of the peculiar conformation 
which forms the subject of our exposition ; it was fully devel- 
oped, round, symmetrical, but hard and solid, the sutures were os- 
sified, the large fontanel firmly covered although not fully ossified. 
The thickness of the bones a little greater than normal. The 
brain did not fully fill the cranial cavity, the meninges were 
much injected with blood, and a copious serous exudation was 
found, in equal proportions, to be contained in the arachnoidean sac. 
The brain itself nowhere soft ; the gray substance was of no un- 
common density, but a little thinner than usual. The white sub- 
stance was of normal color, but of abnormal consistency, the 
substance proving hard, dense, and tough, both when touched in a 
mass, and when cut in slices. Lateral ventricles were narrow 
and contained hardly a drachm of serous fluid. No particular ab- 
normity was found about the cerebellum. 

This last case ajffords a particular interest, from the fact that 
the compression of the brain produced by the early ossification of 
the cranium had no direct consequences, and produced no direct 
cerebral symptoms. The intestinal catarrh beginning the series of 
diseases which terminated fatally, appears to have, together with 
the general bulk of the whole body, gradually diminished the size 
of the brain. Thus when bronchitis and fever set in, with the 
congestion of the meninges consequent thereon, the brain was sub- 



104 

jected to such pressure from the cranium as to be unable to allow 
of any dilatation of the blood-vessels. Up to this time, then, no 
exudation of the arachnoideal sac had taken place. But when a 
sudden attack of cholera infantum exhausted the child, and rapid 
diminution of the body and brain ensued, the general inanition and 
the existing disproportion between the skull and the suddenly di- 
minished volume of the brain resulted in the copious, exudation of 
the arachnoideal sac. Nevertheless this pathological process had 
no influence in changing the former condition of the brain. The 
pressure of the cranium on the brain had previously produced the 
hardness and toughness alluded to, which was still found after a 
part of the cerebral substance had been resorbed in the course of 
several exhausting diseases. Thus this case does not strictly be- 
long to that class of morbid symptoms directly produced by the 
disproportion betwen the cranium and the compressed brain, for 
there have been neither symptoms of compression nor death from 
this cause ; but even this case tends to show the continued and per- 
sistent effect on the cerebral mass which is produced by the early 
closed cranium ; the consistence of the cerebral substance being 
unaltered even after the pressure was removed. 

The other cases are those in which the acute disease was only 
indirectly fatal, the slowly developed but unchangeable dispropor- 
tion between cranium and cerebrum giving rise to those severe 
symptoms which produced death. But without the acute disease 
supervening, the children would either have enjoyed comparative 
health for months or even years, until death had occurred from 
some other cause, or they would have survived to take the chances 
of their general growth and development, liable to the pressure 
on the sclerotic cerebrum, by the early ossified, hyperostotic cra- 
nium. This however seems to be certain, that in the first case a 
slight pneumonia, in the second a few attacks of intermittent fever 
would not have been sufficient to produce the fatal symptoms 
which resulted in death, without the presence of just such path- 
ological anomalies as we have here, described ; and further, that 
the fatal prognosis pronounced from the beginning, was justified, 
we do not say by the final result, but by the prominent pathologi- 
cal facts resulting from the examination during life. 

We desire, then, to remind our readers of the former conclusion, 
that children whose fontanels and sutures are prematurely ossi- 
fied, and who manifest symptoms of cerebral irritation or depres- 



105 

sion, are destined to an early death ; and further, from the argu- 
ments superadded we wffuld deduce the following inference, that 
in all cases of children, whose cranial junctures are prematurely 
ossified, any acute or febrile disease invading the system, slight 
though the acute affection may be, offers a most unfavorable 
prognosis. At all events we feel justified in drawing the conclu- 
sion, that henceforth many cases of infantile diseases which 
terminate unexpectedly and unfavorably, will be at least explica- 
ble to the medical mind, and further that, to give more exactness 
to diagnosis, and more certainty to prognosis, the condition of the 
cranial fontanels and junctures in general will be deemed worthy 
of the closest attention and examination. 



PART II. 



REPORT ON THE PROGRESS OF 0RSTETR1CS, 



AND 



UTERINE AND INFANTILE PATHOLOGY, IN 1858. 



CONTENTS. 



» 

A.— REPORT ON OBSTETRICS AND UTERINE PATHOLOGY. 

Page. 

I. — Manuals and Reports 113 

II. — Anatomy and Physiology of the Uterus and Ovaries 125 

III. — Physiology and Pathology of Pregnancy, Labor, and Puerperal State. . 143 

IV.— Pathology of the Ovaries 167 

V. — Pathology and Therapeutics of Uterine Disease. 

1. General Diagnosis and Pathology 174 

2. Retarded Development, Malformations, and Displacements 185 

3. Uterine and Peri-Uterine Hemorrhages 197 

4. Tumors and Structural Diseases 205 

VI. — Pathology of Bladder, Vagina, and External Genitals !.. 216 

VII. — Physiology and Pathology of the Breasts 229 

VIII.— The Pelvis 232 

IX. — General Diseases of Women during Pregnancy, Labor, and Childbed. . . 235 

X. — Appendages of the Foetus, Extra-Uterine and Multiple Pregnancy 275 

XL— Remedies 283 

XII. — Obstetrical Operations 291 



B.— REPORT ON INFANTILE PATHOLOGY. 

I. — Manuals, General Pathology, Dietetics, Statistics, etc 303 

II. — Dyscrasic and Toxaemic Diseases 324 

III. — Organs of Digestion 342 

IV. — Organs of Circulation 364 

V.— Organs of Respiration 372 

VI. — Organs of the N%rvous System 401 

VII. — Skin and Sensory Organs 424 

VIII. — Organs of the Genito-Urinary System 444 

IX.— Motory Organs 452 



INDEX 

OK 

I 

JOURNALS REFERRED TO IN THE REPORT. 



1. Gazette, the American Medical. . 

2. Journal, the American, of the Medical Sciences. 

3. Journal, Atlanta Medical and Surgical. 

4. Journal, the Boston Medical and Surgical. 

5. Journal, Buffalo Medical. 

6. Journal, the Charleston Medical and Keview. 

7. Journal, the Nashville of Medicine and Surgery. 

8. Journal, the New Orleans Medical and Surgical. 

9. Journal, the Medical of North Carolina. 

10. Journal, the Oglethorpe Medical and Surgical. 

11. Journal, the Pacific Medical and Surgical. 

12. Journal, the Savannah of Medicine. 

13. Journal, the Southern of Medical and Surgical Sciences. 

14. Journal, the Virginia Medical. 

15. Monthly, the American. 

16. News, New Orleans Medical and Hospital Gazette. 

17. Observer, the Cincinnati Medical. 

18. Recorder, Memphis Medical. 

19. Recorder, the Nashville Monthly. 

20. Reporter, the Maine Medical and Surgical. 

21. Review, the North American Medico-Chirurgical. 

22. Transactions of the American Medical Association. 

23. Archives of Medicine. 

24. British Medical Journal. 

25. Chronicle, the Medical,' and Montreal Monthly Journal. 

26. Gazette, the Dublin Hospital. 

27. Journal, the Dublin Quarterly of Medical Sciences. 

28. Journal, the Glasgow Medical. 

29. Journal, Edinburgh Medical. 

30. Journal, the Liverpool Medico-Chirurgical. 

31. Journal, the Midland Quarterly of the Medical Sciences. 

32. Lancet, the Journal of British and Foreign Medicine. (American Edition.) 

33. Reports of Guy's Hospital. 

34. Reports, Ophtalmic Hospital. 

35. Return, Quarterly of Registrar-General. 

36. Review, the British and Foreign Medico-Chirurgical. 

37. Times, the Medical, and Gazette. 

38. Transactions of the Royal Medico-Chirurgical,Society. 

39. Transactions of the Pathological Society of London. 

40. Archiv fiir Physiologische Heilkunde. 

41. Archiv fiir Patholog. Anatomie und Physiol ogie und fiir Klinische Medicin 

42. Beitrage zur Geburtskunde und Gynaekologie. 

43. Centralzeitung, Allgemeine Medicinische. 

44. Correspondenz-Blatt, Wurtemberger Medicin isches. 

45. Intelligenz-Blatt, Aerztl. Organ fiir Bayern's staatl. und ofFentliche Heilkunde 

46. Jahrbiicher der Gesammten In- und Auslandischen Medicim 

47. Jahrbuch fiir Kinderheilkunde und Physische Erziehuug. 

48. Jahrbiicher, Konigsberger Medicinische. 

49. Journal fnr Kinderkrankheiten. 

50. Klinik, Deutsche. 

51. Literaturblatt, Aerztliches. 



VI INDEX OF JOURNALS REFERRED TO IN THE REPORT. 

52. Memorabilien aus der Praxis. 

53. Monatsblatt fiir Medicinische Statistik und ofFentliche Gesimdheitspflege. 

54. Monatshefte, Medicinisch-Chirurgische. 

55. Monatsschrift fiir Geburtskundc und Frauenkrankheiten. 

56. Monatsschrift, Sckweizerische, fiir Praktiscke Medicin. 

57. Organ fiir die Gesammte Heilkunde. 

58. Sitzungsberichte der Mathematisch-Pbysicalischen Klasse der K. K. Aka- 

demie der Wissenschaften zn Wien. 

59. Untersuchungen zur Naturlehre des Menschen und der Thiere. 

60. Yerhandlungen der Physikalisch-Medicinischen Gesellschaft zu Wiirzburg. 

61. Yierteljahrschrift fiir Geriehtliche und Oeffbntliche Medicin. 

62. Yierteljahrschrift der Prakt. Heilkunde der Medicin. Fakultat zu Prag. 

63. Wochenschrift, Wiener Medicinische. 

64. Zeitschrift, Oesterreichische, fiir Praktische Heilkunde. 

65. Zeitschrift fiir Klinische Medicin. 

66. Zeitschrift der K. K. Gesellschaft der Aerzte zu Wien. 

67. Zeitschrift fiir Wundarzte und Geburtshelfer. 

68. Zeitschrift, Ungarische, fiir Natur- und Heilkunde. 

69. Zeitschrift fiir Wissensckaftliche Zoologie. 

70. Zeitschrift, A. Henke's, fiir Staatsarzneikunde. 
, 71. Zeitung, Allgemeine Wiener Medicinische. 

72. Zeitung, Medicinische llussland's. 

73. Zeitung, Medicinische, vom Yerein fiir Heilkunde in Preusseu. 

74. LAbeille Medicale. 

75. Annales de la Flandre Occidentale. 

76. Annales Medico-Psyckologiques. 

77. Annales d'Oculistique. 

78. Archives Generates de Medecine. 

79. Bulletin de TAcademie Imperiale de Medecine. 

80. Bulletin des Traveaux de la Societe Imperiale de Marseilles. 

81. Bulletin de Therapeutique. 

82. Comptes Rendu des seances de TAcademie des Sciences. 

83. Echo medical Suisse. 

84. Gazette hcbdomadaire de Medecine et de Chirurgie. 

85. Gazette des Hopitaux. *> 

86. Gazette medicale de Lyon. 

87. Gazette medicale de Paris. 

88. Gazette medicale de Strasbourg. 

89. Journal de medecine Beige. 

90. Journal de medecine de Bordeaux. 

91. Journal de medecine de Bruxelles. 

92. ^Journal de medecine de Toulouse. 

93. Journal de la Physiologic de l'homme et des animaux. 

94. Memoires de TAcademie Beige. 

95. Memoires de la Societe de Chirurgie de Paris. 

96. Memoires de TAcademie imperiale de Medecine de Paris. 

97. Moniteur, le, des Hopitaux. 

98. Presse medicale Beige. 

99. Eevue medical, Franchise et etrang. 

100. Kevue the therapeutic medico-chirurgicale. 

101. L'Union, medicale de Paris. 

102. L'Union, medicale de la Gironde. 

103. Gaceta medica de Lima. 

104. Bulletino delle scienze medico-fisiche di Bologna. 

105. Gazetta Medica, dei Stati Sardi. 

106. Gazetta Medica di Lombardia. 

107. II Filiatre Sebezio. 

108. Siglo, el, Medico. 

109. Bibliothek for Lager. 



113 



L— MANUALS AND REPORTS. 

1. The Principles and Practice of Obstetrics, including the Treatment of 
Chronic Inflammation of the Uterus, considered as a Frequent Cause 
of Abortion. By Henry Miller, M.D., Professor of Obstetric Medi- 
cine in the Medical Department of the University of Louisville, Ky. 
With Illustrations on wood ; pp. 624. Philadelphia : Blanchard & 
Lea. 1858. 

2. A Manual of Obstetrics : Theoretical and Practical. By W. Tyler 
Smith, M.D. 12mo., pp. 628. London, 1858. 

3. TraiU theorique et pratique de Vart des accouchements, comprenant Vhis- 
stoire des maladies qui peuvent se manif ester pendant la grossesse et le 
travail, Vindication des soins a donner a V enfant, depuis la naissance 
jusqu' a Vepoque du sewage. Par P. Cazeaux. 6me. edit. 8vo. Paris, 
1858. 

— A Theoretical and Practical Treatise on Midwifery, etc. By P. 
Cazeaux, M.D. 6th edit. Paris, 1858. 

4. Lehrbuch der Geburtshulfe. Von Dr. Otto Spiegelberg. Mit 80 in 
in den Text gedruckten Holzschnitten. pp. 376. Lahr, Schauen- 
burg & Co., 1858. 

— Manual of Obstetrics. By Otto Spiegelberg, M.D. With 80 wood- 
cuts, etc. Lahr, Schauenburg & Co., 1858. 

5. Lehrbuch der Geburtshulfe fur Hebammen. Von Dr. F. C. Naegele. 
lOte Aufl. pp. 550. Heidelberg, J. C. B. Mohr. 1858. 

— A Manual of Obstetrics for Midwifes. By F. C. Naegele, M.D., 10th 
edit. Heidelberg, etc. 

6. Elements of Practical Midwifery, or Companion of the Lying4n 
Room. By Charles Waller, M.D., Obstetric Physician to, and Lect- 
urer on Midwifery at St. Thomas's Hospital. Fourth edit, with 
plates. 12mo., pp. 193. London, 1858. 

7. Traite pratique des maladies des organes sexuels delafemme, par M. 
Scanzoni, Professeur d'accouchements et de gynaecologie a Puni- 
versitd de Wurzbourg ; traduit de l'Allemand et annote" sous les 
yeux de l'auteur par les docteurs Dor et Socin. Paris, 1858. 

— A Practical Treatise on the Diseases of the Female Sexual Organs. By 
Scanzoni, etc. — Translated from the German by Drs. Dor and 
Socin. Paris, 1858. 

8. Lecons cliniques sur les maladies de I' uterus et de ses annexes. Par le 
Dr. F. A. Aran, Medicin de l'hopital St. Antoine, Professeur agrege" 
de la Faculty de Medicine de Paris. Paris, Labe* 2 vol. 8vo. 
1858 (not complete). 

— Clinical Lectures on the Diseases of the Uterus, etc. By F. A. Aran, 
M.D. etc. 

9. Lectures on the Diseases of Women. Part II. Diseases of the Ovaries, 
etc. By Charles West, M.D., etc. London : John Churchill. 1858.. 

8 



114 

10. Practical Midwifery, comprising an Account of 13,478 Deliveries 
which occurred in the Dublin Lying-in Hospital, By E. B. Sinclair, 
A.B., T.C.D., and George Johnston, M.D. London, 1858. 

11. Verhandlungen der Gesellshaft fur Geburtshulfe in Berlin. 10. Heft. 
Mit 2 Taf. Abbildungen. gr. 8. pp. 204. Berlin, A. Hirschwald. 

— Transactions of tlie Berlin Obstetric Society. 10th Vol. With 2 
plates, etc. 

12. Bericht uber die Thdtigkeit und Verhandlungen der Gesellschaft fur 
Geburtshulfe zu Leipzig, erstattet von E. P. Meissner. — In Monat- 
schrift ftir Geburtshulfe. Juni, 1858. 

— Transactions of the Leipsic Obstetrical Society, etc. By E. P. Meiss- 
ner. — In Monatschrift f. Geburtsh. June, 1858. 

13. Drei und vierzigster Jahresbericht der Gebaranstalt derkbnigl. S'dchsi- 
schen medic.-chirurg . Academie zu Dresden. — In Monatschrift fiir Ge- 
burtshiilfe. XII. 6. Dec. 1858. 

— Forty-third Annual Report of the Lying-in Hospital of the Royal Me- 
dico-chirurg . Academy at Dresden. By Grenser, M.D. — In Monat- 
schrift fur Geburtsh. XII. 6. Dec. 1858. 

14. Bericht uber die Vorfdlle in der geburtshulflichen and gynaekologischen 
Klinik und Poliklinik zu Jena, wdhrend der Jahre 1855, 1856, 1857. 
Von Ed. Martin.— In Monatschrift f. Geburtsh. XII. 3. Sept. 
1858. 

— Report of the Obstetrical and Gynaekolog. Clinic of Jena, for 1855, 

1856, 1857. By Dr. Ed. Martin, M.D.— In Monatschrift f. Geb. XII. 
3. Sept. 1851. 

15. Jahresbericht von der geburtshulflichen Klinik fur Hebammen in 
Wien, fur das Jahr 1857. Von Dr. Habit. — In Zeitschrift der Ge- 
sellshaft der Aerzte zu Wien. No. 21, 22, 23. 1858. 

— Annual Report of the Obstetric Clinic for Midwifes in Vienna, for 

1857. By Habit, M.D. — In Zeitscrift d. Gesellsch. d. Aerzte zu 
Wien. Vol. 21, 22, 23. 1858. 

1 6. Bericht uber die Leistungen der unter der Leitung des Hofrath und 
Prof. Dr. v. Scanzoni slehenden geburtshulflichen Klinik zu Wurz- 
burg, vom 1. Nov. 1853 bis 31. Octob. 1856. Von Dr. J. B. Schmidt. 
— In Scanzoni's Beitrage z. Geburtsk. Bd. 3. 1858. 

— Report of the Obstetrical Clinic of Prof. Scanzoni at Wurzburg, 
from Nov. 1, 1853 to Octob. 31, 1856. By J. B. Schmidt, M.D.— 
Scanzoni's Beitrage z. Geburtsk. Vol. 3. 1858. 

17. Report of the Committee of Obstetrics of the Ohio State Medical So- 
ciety. By J. G. F. Holston, M.D. — In Transactions of the Ohio 
State Med. Soc. 1858. 

18. Report on Uterine Diseases. By R. McMeens, M.D. — In Trans- 
actions of the Ohio State Med. Soc. 1858. 

19. A Report on Diseases of the Cervix Uteri. — Read before the Medical 
Society of the State of Georgia. With additional notes by Joseph 
A. Eve, M.D., Prof, of Obstetrics and Diseases of Women and 
Children in the Medic. College of Georgia. 



115 

20. Tabellariscche Zusammenstettung der Ereignisse in der geburtshulf- 
lichen Klinik zu Wurzburg wdhrend der 6 Jahre vom 1. Novbr. 1850 
bis 31. Oct. 1856. Von Dr. Gregor Schmitt. — Scanzoni's Beitrage. 
B. 3. 

— • Tabular y Review of Births Observed in the Obstetrical Clinic of Wurz- 
burg during the six Years from Nov. 1, 1850 to Octob. 31, 1856. By 
G. Schmitt, M.D. 

The past year has been unusually fruitful in manuals and hand- 
books, an accumulation of science which is certainly not required in 
our time. We are already in possession of so many excellent books 
of this kind, that there will be no need in this direction for the next 
decennium. On the other hand, their value is undeniable for the 
student of obstetrical science, inasmuch as he is thus enabled to 
recur to the teachings of his master in case of need, having at once 
occasion to make himself acquainted with the most recent state of 
science. 

Dr. Miller's work is essentially utilitarian in its aim, fairly repre- 
senting the present state of obstetric science in this country. Dr. 
Miller dwells more particularly on a subject which of late has much 
occupied the attention of the profession, viz., the influence of inflam- 
mation and ulceration of the cervix uteri upon the course and pheno- 
mena of pregnancy. His views upon this subject appear to be iden- 
tical with those which were promulgated in France and England 
some fourteen years ago. He says that the most prolific cause of 
abortion consists in a diseased state of the gestative organ, either in 
whole or in part ; that when a portion only is affected, it is the cer- 
vix rather than the body ; and that as to the particular disease itself, 
it is inflammation of the uterine mucous membrane, which may 
invade also the parenchyma of the organ. In support of this opinion 
he, however, merely alleges that in his experience he has had many 
opportunities of verifying the frequent existence of inflammation, 
with ulceration of the cervix uteri, during pregnancy, and of satisfy- 
ing himself that it is not an uncommon cause of abortion. To sup- 
port his view on this subject he points to analogous phenomena in 
other departments of the system. Gastro-enteritis, for example, he 
says, quickens and perverts the peristaltic motion of the alimentary 
canal, and leads to the precipitate ejection of its contents, not permit- 
ting the food to remain a sufficient length of time to be digested. In 
this case the food may be said to be prematurely expelled, just as 
the ovum is liable to be, when the organ it inhabits is inflamed. 

With regard to the important chapter of puerperal hemorrhage, 
Dr. Miller protests strongly against artificial delivery in cases of 
placenta prsevia, referring to the want of success which has attended 
it, as indicated by the statistical data collected by Drs. Simpson, 
Trask, and others. As a substitute for turning, he proposes a modi- 
fication of a method of Puzos, which consists in originating expulsive 
contraction of the uterus by the tampon or plug, and then puncturing 
the membranes, relying on the tampon to control the flooding until 
the liquor amnii is evacuated. Dr. Miller asserts to have employed 
this method with uniform success so far as the mother is concerned. 



116 

Dr. Smith writes in a peculiarly attractive style, and in conveying 
his information he does it in his own words, instead of compiling 
quotations from other writers, whereby his influence over the mind 
of the student is generally increased. The physiological and theo- 
retical portions of the book are exceedingly good. Altogether, the 
book is well fitted for leading students to become good and scientific 
practitioners. In page 62, quite a new suggestion is offered as to 
the nalure of menstruation. Dr. S. believes that at each menstrual 
period the mucous membrane of the uterus is, in great part, or 
entirely, broken up, and its debris discharged, and that a new mem- 
brane is formed as a preparation for the reception of a fecundated 
ovum. This idea is reasonably supported by many well stated facts. 
The chapters on physiology and mechanism of labor are very 
good, and convey a correct idea of the process. 

In regard to the time when the placenta ought to be removed, we 
think that ten minutes is too short a time as a general rule. It is 
better to wait for a few efficient contractions of the womb, and let 
the woman enjoy some rest from the last and hardest stage of labor. 
The chapters on the management and retention of placenta require a 
larger share than is allowed to them by the author, because here the 
student finds his first puzzles when entering upon his practical 
career. The advices for management of the puerperal state are very 
reasonable, especially in regard to the diet, allowing nourishing food 
aB soon as the secretions are fairly reestablished. 

Deficiency of the lochia from retention means to say, we suppose, 
from retention of blood-coagula in the womb ; at least the treatment re- 
commended admits no other explanation. The chapter on convulsions 
is very good in every respect. And we only can repeat, that the 
book is highly recommendable for students as well as practitioners. 
Cazeaux's work is distinguished by extraordinary elaboration, 
redundancy of detail, and great freedom of style. With regard to 
ulcerations met with on the cervix uteri during pregnancy, and their 
influence upon the production of abortion and puerperal disease, 
he thinks that their importance had been greatly exaggerated, 
especially of those occurring in the latter half of gestation, most of 
which he regards as the normal condition, as a consequence of the 
progress of gestation. He is convinced of their non-injurious char- 
acter, and therefore regards all treatment employed against these 
ulcerations, even when fungoid, as much more hurtful than useful. 
Dr. Grisolle's views on the reciprocal influence of pregnancy and 
parturition upon the progress of phthisis are endorsed by Dr. Cazeaux. 
Contrary to the general belief, they tend to show that neither preg- 
nancy nor delivery affects sensibly the progress of phthisis, nor does 
the latter sensibly disturb the course of the former. The relations of 
albuminuria to puerperal convulsions have been very carefully inves- 
tigated by M. Cazeaux. He insists very strongly upon its import- 
ance in the etiology of the disease, but regards it rather as its 
.predisposing than exciting cause. He is strongly opposed to the 
employment of anaesthetic inhalations in the treatment of this dis- 
ease. With regard to the induction of premature labor, our author 
lays it down as a rule, that it should not be undertaken before the 



117 

end of the seventh month of pregnancy, and that the smallest pelvic 
diameter should not be less than two inches and three quarters. Of 
all the methods employed for this purpose, he almost exclusively 
recommends the use of Kiwisch's uterine douche. The operation for 
the production of abortion is, in the opinion of our author, perfectly 
justifiable in certain cases, such as extreme contractions of the pel- 
vis, voluminous tumors of the excavation, extreme dropsy of the 
amnion, irredeemable displacements of the womb, and haemorhages 
which have resisted the employment of the most rational means for 
their suppression. With regard to the Caesarian operation, M. 
Cazeaux believes that the child ought to be sacrificed whenever the 
delivery can be effected by embryotomy. Rejecting the use of 
anaesthetics in normal labor, Dr. Cazeaux proposes their administra- 
tion in the following cases : 1. For calming the extreme agitation 
and mental excitement which labor often produces in very nervous 
women. 2. In those cases in which labor appears to be suspended 
or much retarded by the pain occasioned by previous disease, or 
such as may supervene during labor, as cramps, colic, vomiting, 
compression of the sciatic nerve, etc. 3. In cases of irregular or 
partial contraction. 4. Spasmodic contraction, or rigidity of the 
cervix uteri. 5. Cases of eclampsia, restricted to those which ap- 
pear to be manifestly due to the local irritation of an organ, whose 
extreme sensibility had excited the reflex-action of the spinal nerves. 
6. Obstetrical operations, which are productive of much pain, or 
necessitate quiescence on the part of the patient — such as turning, 
symphyseotomy, or the Caesarean. 

Dr. Spiegelberg's manual of obstetrics, although a part of a medi- 
cal Cyclopaedia, may be considered as a work of itself, as it com- 
prises the entire field of obstetric science. One of its greatest 
advantages is its practical tendency, aside from theoretical and 
sophistical speculation, while all the scientific researches of our 
time are duly recorded as far as they have regard to the physiology 
of pregnancy and parturition. The first pages are occupied with the 
description of the abdomen and pelvis. When speaking of the differ- 
ent diameters of the pelvis, our author mentions the so-called normal 
conjugata (G. H. Meyer), which is represented by a line, the posterior 
terminus of which is located in the third lumbar vertebra, while its 
anterior extremity reaches the superior edge of the symphysis pubis, 
between the two tubercula pubis. After this follows a description 
of the external parts ; of the breasts ; the obstetrical examination ; 
the physiology of pregnancy and of the puerperal state. On page 
45. M. Spiegelberg mentions the development of sebaceous glands 
around the nipple as a sign of pregnancy, and ascribes to Dr. 
Montgomery the honor of having first called attention to this circum- 
stance. This is not quite correct. It was Prof. Roederer, of Got- 
tingen, who first (1153) mentioned the coincidence of pregnancy 
with enlargement of the glands, situated in the areola of the nipple. 
The cause of the position of the foetus in utero with its head down- 
wards, is attributed to the gravity of the latter, aided by the confor- 
mation and reflex actions of the uterus itself. Therefore, cross- 
presentations are very often met with in an abnormal state of the 



118 

uterus, and with deformed children. For the same reason, prema- 
ture and dead children rarely present with the head, because their 
specific weight is altered under these circumstances. The chapter 
on diagnosis of pregnancy opens with a consideration of the circula- 
tory, cardiac, and umbilical sounds. The first of these is owing to 
the alteration of the circulation of blood in the uterine walls, in some 
cases to compression of the large pelvic vessels, and to a dilatation of 
the epigastric artery. Therefore it cannot be considered as a certain 
sign of pregnancy. The umbilical souffle takes its origin in the 
arteries of the cord, whenever the navel-string is exposed to pres- 
sure. The cause of the first labor pains is put down as a conse- 
quence of an altered circulation of the uterus, leaving it undecided 
whether a state of anaemia or of hypereemia is formed, although it is 
more likely that the latter condition acts as an exciting cause to 
labor, produced by the catamenial afflux of blood to ovaries and 
uterus. In the chapter on physiology and dietetics of childbed, our 
author mentions the fact that still-born childreu may be resuscitated 
even after a lapse of a couple of hours. The pathology of gestation 
comprises, 1. Those affections which may be considered as an 
increased or altered physiological condition of the pregnant state. 
2. Those accidental diseases which are unconnected with gestation. 
With regard to the treatment of placenta preevia, the vaginal plug 
is warmly and justly recommended. The predisposing element in 
the development of uraemia, one of the many causes of eclampsia, is 
the peculiar condition of the blood of pregnant women. As it is con- 
stituted very much like that of chlorotic persons, it has a tendency 
to the formation of oedema, to transudations, to the passage of 
albumen and fibrin through the kidneys, and to excite the nervous 
system of pregnant women. The performance of the accouchement 
force is surrounded with the most serious dangers, and its execution 
must, therefore, be restricted to those cases where the life of the 
mother is actually threatened by a long continuation of eclamptic 
attacks. The use of chloroform is invaluable, inasmuch as its appli- 
cation retards the evil influence of the convulsions upon the system, 
thus giving time to the accoucheur to apply whatever remedies he 
thinks proper to choose for promoting delivery. In the chapter on 
uterine haemorrhages, the prolapsus placentae is duly mentioned. 
The diagnosis of this accident meets with no difficulties, when the 
afterbirth protrudes from the os uteri, while it is more difficult to 
recognize the true nature of the case, when only a small section of 
the placenta has come down near the edge of the os uteri, and in 
this instance it is generally mistaken for placenta preevia. This pro- 
lapsus is always fatal for the child, while the prognosis for the 
mother is better, because the haemorrhage is not so violent as that in 
consequence of placenta preevia. The collapse after delivery is due 
to a perfect exhaustion of the central nervous system produced by 
the efforts of labor. This exhaustion is mostly met with in tender, 
irritable women, who are little used to muscular exertions. But it is 
also observed in strong and healthy women, after very rapid deliv- 
eries. In this latter instance, the syncope is explained by cerebral 
anaemia, in con£equence*of a strong and sudden congestion of the ab- 



119 

normal organs. In both cases, chloroform is the remedy. The last 
section of the work contains a description of the different obstetrical 
operations. Altogether the work before us is all that can be 
expected from a treatise of this kind. It will undoubtedly take a 
prominent place among the numerous manuals of obstetric science 
and art. 

Dr. Waller's work contains a short exposition of obstetric science, 
and is intended as a manual for students and young practitioners. 
It is extremely meagre and commonplace in its details — exhibits but 
little power of analysis or condensation on the part of the author. 
The question of the extraction of the placenta in certain cases of 
placenta preevia, and the general employment of anaesthetics in mid- 
wifery, are treated of more fully. 

Dr. Scanzoni's work is a concise treatise on the pathology of 
female diseases, with the exception of those occurring during preg- 
nancy, labor, and the puerperal state. The author recognises four 
different forms of ulcerations — 1. The erosion, which owes its origin 
to a previous or existent uterine catarrh. It sometimes is preceded 
by a vesicular, aphthous eruption, and in this instance generally 
connected with an abnormal condition of the blood. M. Scanzoni 
attended an otherwise healthy woman, affected with aphthee of the 
mouth, who, with every new eruption, exhibited also fresh blisters 
on the mucous membrane of the vaginal portion. She was finally 
cured by country air and bathing in the river. 2. This erosion, after 
some time, assumes the character of an ulceration, which takes a 
granular appearance by consecutive hypertrophy of the papillee in 
the mucous membrane. This kind of ulceration is always connected 
with structural changes of the uterus itself, mostly with chronic en- 
gorgement and catarrh, both of which must be considered, in some 
cases, as the cause, in others as the consequence of this ulceration. 
Its presence constantly keeps up a state of congestion of the womb 
and its appendages, thus producing and increasing pathological con- 
ditions in and around the uterus. These ulcerations never heal spon- 
taneously, but have a tendency to spread in all directions. 3. 
Fungous ulcerations are those which have a development of vascular 
cellular tissue ; they proceed deeply into the cervical canal, and are 
always the seat of an abundant puriform secretion, bleeding spon- 
taneously and when touched. 4. Varicous ulcerations are rarely met 
with, having their origin in a chronic stasis in the uterine walls. At 
the beginning of the disease the vaginal portion has a blueish red 
hue, like the appearance in advanced pregnancy ; afterwards dark 
spots and varicous veins are observed, upon which the softened 
mucous membrane forms slight elevations. Finally, the epithelium 
decays, and the erosion, with a blueish red and vascular base, in- 
creases to a broad ulceration. The erosion is, in most instances, 
curable in four weeks. The treatment should be begun with the appli- 
cation of leeches, to be followed by the application of a caustic solution 
(arg. nitr. 9i, aqu. |i) every five or six days. The granular ulcer- 
ation demands repeated local depletion every sixth or eighth day, 
warm hip-baths, alum injections, stronger cauterizations, and the use 
of aperient mineral waters. The excrescences of the fungous ulcer- 



120 

ation have to be removed as much as possible with scissors, and 
afterwards a strong caustic solution ought to be brushed over the 
diseased surface as far as it extends into the cervical cavity. Gene- 
rally, the excision has to be repeated four or six times ; instead of 
leeches, blood ought to be abstracted by scarifications. 

One hundred and eight women, afflicted with cancer uteri, came 
under the author's treatment, and seventy-two of them had borne a 
large number of children (four to eleven). The most important pre- 
disposing causes to cancer seem to be depressing mental emotions ; 
it was possible to trace the origin back to this source in eighty-four 
cases ; in fifteen patients excesses in venere were admitted ; in 
eight patients chronic engorgement, with or without ulceration, pre- 
ceded the development of cancer. Only three cases of neuralgia 
uteri came under the author's notice, and only one of them was cured 
— by marriage. In small, unilocular ovarian cysts, good results 
were obtained by Kiwisch's method, a catheter being left in the 
opened cyst ; eight patients in fourteen being radically cured ; three 
leaving before the treatment was concluded ; one dying two months 
after the operation from typhus fever ; while in two of them the cyst 
filled anew. The operations performed for atresia vaginae had such 
unfavorable results, that Dr. S. has abandoned operating upon the 
vagina, and resorted to puncturing per rectum, in the hope that this 
operation will prove more satisfactory. 

Dr. West's work, although chiefly occupied by descriptions of and 
discussions on ovarian disease, contains several chapters of other 
subjects. The three last are on diseases of the external organs of 
generation, of the urethra and vagina, and of the female bladder ; 
while the two first are on inflammation of the uterine appendages, 
seven chapters remaining for the diseases of the ovary. A great 
number of cases, usually put down as acute or chronic ovaritis, 
ovarian irritation, and pains in the unimpregnated female, are 
actually very often the results of acute and very limited peritonitis. 
In twenty-one out of sixty-six instances in which Dr. West examined 
the uterus and its appendages, the ovaries themselves, or parts im- 
mediately connected with them, presented changes, more or less 
obviously due to inflammatory action. In ten of the twenty-one 
cases, the main evidence of inflammation consisted in traces of old 
peritonitis of the uterine appendages ; and in five of the number 
there was no evidence of mischief. The amount of this peritonitis 
varied accordingly. In some instances its results were nothing 
more considerable, than a thin and partial layer of false membrane 
on the surface of one or other ovary, and long*, filamentous adhesions 
between the ovary and fallopian tube. In other cases a complete 
web of false membrane enveloped the ovaries, thickened the broad 
ligaments, and by its contraction shortened the ovarian ligaments. 
Acute inflammation of the proper tissue of the ovary is occasionally 
a phenomenon of puerperal fever, as it occurs at an early stage of 
ovarian dropsy ; but apart from this it is not a common affection of 
the unimpregnated female. 

A frequent disease at this region is ovarian pain. It is generally 
aggravated at the menstrual period, and often connected with dis- 



121 

ordered general health, in most cases easy to mitigate, but very hard 
to cure. Leeches and blisters sometimes afford ease for a shorter or 
longer space of time ; chloroform locally applied gives temporary 
relief. The camphor liniment, with extract of belladoma. is another 
external application which Dr. West has found advantageous ; and 
when these means have been fruitless, the tincture of aconite has 
been applied with advantage. Attention to the general health must 
always go hand in hand with the local treatment — must indeed hold 
the first place. The tonics which do the most service are the sulphate 
of quinine and the valerianate of zinc. 

The appearance of ovarian cyst is observed almost invariably 
within the child-bearing period of life. The characteristic forms of 
this disease are believed by Dr. West to take their origin in one or more 
graafian vesicles. Small ovarian cysts are often observed to have 
contents, more or less like those of a graafian vesicle, and sometimes 
even a little clot of blood, the analogue of a healthy condition of the 
part, the graafian vesicular menstruation. To complete the proof, 
Rokitansky has discovered an ovule in a young ovarian dropsy. But 
while the graafian vesicular origin of the disease in many cases is 
admitted, others cannot be excluded ; at any rate the question 
remains undecided. Dr. West is of opinion that a cyst, originally 
barren, may become proliferous ; that its continuing simple is rather 
a happy accident than a condition, on the permanence of which we 
cannot calculate with any certainty. The different means for curing 
an ovarian cyst are — 1. Excision. 2. Injection with a solution of 
iodine. 3. Tapping of the main cyst. 4. The ovarian dropsy may 
be let alone. After the researches of Dr. West, one of two dies after 
ovariatomy. Of the cases in which the operation is attempted, it is 
left unfinished in about one-third, and of these latter, again, about 
a third terminates fatally. Dr. West, therefore, rejects ovoriatomy, 
and is greatly in favor of iodine injections The operation of tapping 
per vaginam, and subsequently keeping the wound open, has as yet 
been little practiced, but the results seem to encourage further trials. 

Messrs. Sinclair and Johnston's work on Practical Midwifery, con- 
sists of an account of 13,748 deliveries which occurred in the Dublin 
Lying-in Hospital during the seven years of Dr, Skeleton's master- 
ship, while the authors were assistant-physicians for the greater 
part of that period. The preface of the work contains an interesting 
account of the origin, progress, and management of the hospital, and 
a description is also given of the general routine treatment which 
patients undergo from the time of their entrance to their discharge 
when convalescent. All labors are arranged under four principal 
heads : — 1. Natural. 2. Difficult. 3. Preternatural. 4. Anomalous. 
The proportion of male to female births is 105 boys to every 100 
girls. The total number of still-born children was 968, or about 1 
in every 14 of those born. Of these, however, 487 were putrid at 
the time of birth. Of the 481 non-putrid children, 284 were males 
and t 197 females, which shows that male children are exposed to 
greater risks immediately before and during birth than females. 
The total number of maternal deaths from all causes was about 1 in 
84 ; deducting, however, 17, which were admitted dying in the 



122 

hospital ; the mortality was 1 in 94. Of the 163 women dying from 
all causes, 40 died from other than puerperal ones, thus leaving 123 
deaths out of 13,748 deliveries directly traceable to the labor; or 
about 1 in every 111 women delivered died from puerperal causes. 
In the months of December in each year, the greatest mortality was 
found to prevail, the ratio being 1 in 46, and the lowest in May, the 
ratio being 1 in 184. Of those labors which terminated within the 
first hour, 1 in 110 mothers died ; while of those women who were 
delivered during the second and third hours, only 1 in 243 died. In 
the first six hours the proportion of maternal deaths is 1 in every 
178 ; from seven to twelve hours, 1 in every 144 ; and from thirteen 
to twenty-four hours, 1 in every 124. In those cases where labor 
was prolonged beyond twenty-four hours, but in which there was no 
interference, the mortality reaches as high as 1 in every 20|. 

The forceps deliveries amounted to 200, and the craniotomy cases 
to 130. The mortality in the forceps cases amounted to 11 mothers, 
or about 1 in 18 ; and 17 children, two of the latter being putrid at 
birth. Of the craniotomy cases, 26 mothers died, or 1 in every 5. 
In using the forceps, traction was made during a pain only, in the 
direction of the axis of the pelvis, and no motion whatever was 
permitted in a lateral direction. Craniotomy was never had recourse 
to when the forceps could be applied, even if the child's heart had 
never been heard during labor. 

In prolapse of the funis, considerably more than one-half of the 
children were lost. Accidental hemorrhage occurred in 81 labors, 4 
mothers dying and 27 children being dead-born ; instrumental inter- 
ference was needed in 8 cases. Of placenta prsevia, only 24 in- 
stances occurred in the entire number of deliveries. Of these, how- 
ever, 6 mothers died. Of the 8 cases of complete placental 
presentation, only 3 recovered, and only 3 children were born alive. 
The treatment adopted was according to the circumstances of each 
particular case In all cases of post-mortem hemorrhage, a stream of 
cold/water was thrown into the uterus, and with the best success. 
Induction of premature labor was performed in 4 cases, and each of 
the mothers recovered, but only 1 child was saved. In two cases, 
where it was induced on account of general dropsy, both mothers 
died. Chloroform was given in nearly all cases before operation, 
and during the seven years not a single accident took place that 
could be attributed to the use of chloroform. Of puerperal fever, 
which, however, never appeared in a severe epidemic form, 129 
cases are reported, or 1 in every 106 of the whole. Eighteen cases 
of trismus neonatorum are present in this report,' and all died within 
ten days ; it seemed to make its appearance in an epidemic form. 

From Dr. Grenser's report we take the following data. In 1857, 
433 pregnant women were received in the Dresden Lying-in Hos- 
pital. Of 412 deliveries, 373 were effected without surgical inter- 
ference ; 20 by the forceps, 1 by turning, 5 by extraction, 3 by per- 
foration and cephalotripsis, 1 by accouchement force" ; while in nine 
cases artificial removal of the placenta was required. All the women 
recovered with the exception of 5 ; out of this number 2 died from 
peritonitis, 1 from pyaemia, 1 from uraemia, and 1 from ruptura uteri. 



123 



The number of new-born children was 414, among whiph were two 
pairs of twins, altogether 219 boys and 195 girls ; 18 male and 6 
female children were still-born, and all of them resuscitated ; 13 
boys and 9 girls died before delivery, 4 in far advanced maceration, 
1 immature, 3 from pressure of the cord, 1 from internal hemorrhage 
in consequence of uterine rupture, 3 from compression of the brain 
during the passage of the head through a contracted brim, 3 from 
protracted labor, with consecutive craniotomy. 
The presentations were as follows : 



303 in I. 
89 in II. 
3 in III. 
linl. 
1 in II. 



cranial. 



facial. 



4 in I. 
6 in I. 
2 in II. 
1 in II. 



breech, 
feet. 

shoulder. 



In 4 cases the presentation was not noted. 

The largest placenta was 8 and 9 inches in its diameters, the 
smallest 4, while 45 placentas had fibrinous, and 5 had calcareous 
deposits on their uterine surface. 

The indications for the 20 forceps operations were : 9 for increas- 
ing diminution of the foetal pulsation in force and frequency ; 5 for 
prolapsus of the funis ; 1 for imminent suffocation of the mother, in 
consequence of a large struma lymphatica ; 1 for eclampsia ; 1 for 
internal haemorrhage from ruptura uteri ; 1 for metrorrhagia in the 
last stage of labor ; 3 for rhachitic contraction of the pelvis. Five 
out of these 20 children were born dead ; 5 were still-born, and 
revived ; 2 mothers died ; 1 from eclampsia ; 1 from ruptura uteri. 

From the statistical tables reported in Dr. Martin's report, we take 
the following facts : 

1855. — Of 88 new-born children (1 pair of twins and 4 still-born), 
38 were of the male, 50 of the female sex. Obstetrical operations 
were required 35 times, among which was 1 Caesarian operation 
post mortem, giving a dead child ; 15 forceps operations ; 4 crani- 
otomy-forceps operations. 

1856. — Of 111 children born in the hospital, 4 were still-born, and 
1 pair of twins. In the polyclinic, 1 case of premature quadruplets 
was observed. The examination of the afterbirth showed that three 
ovules had been fructified. There were altogether 98 cases of dys- 
tocia (out of 159 deliveries) and 31 operations, among which were 
18 forceps operations. 

1857. — Of 164 deliveries, 1 cases of twins occurred, giving a total 
of 111 children born, among which were 100 males and 11 females ; 
16 of them died before or during confinement. In these 164 cases, 
46 operations were required. The transfusion of blood was success- 
fully performed in a case of haemorrhage from placenta praavia. 



PRESENTATIONS. 



Naegele's I. Cranial presentation 
" II. " " 

" III. " " 

" IV. " " 

Undecided " " 

Facial presentation, I. 



.224 
.119 
. 2 
. 1 
. 9 
1 
Presentation of nates, L 3 



Presentation of nates, II 1 

Foot presentations, 1 2 

" II 3 

Knee presentation 1 

Transverse presentations 2 

370 



124 

After 52 forceps operations, 2 mothers and 5 children died. 

Dr. Habit's report contains the following" : There remained from 
last year 80 pregnant women, tt in childbed, 6t children ; 3,835 
pregnant women received in the hospital, of which 3,t95 were de- 
livered, 33 dismissed undelivered, 8t remained at the end of the 
year. Of 3,872 women in childbed, 3,t02 were dismissed healthy, 
83 died, 8t remained. Of 3,t2t children, 1,965 were males, and 
l,t62 females ; 119 were still-born (65 males, 54 females) ; dis- 
charged 3,568 children, 146 died, 80 remained ; 860 were so-called 
" gassengeburten" (i.e., women delivered immediately before enter- 
ing the hospital) ; premature confinements, 249 ; twins, 51 ; 3,663 
cranial presentations, 2t face presentations, 95 foot and nates pre- 
sentations, 52 cross presentations. The operation of turning upon 
the head was performed in 21 cases, upon the feet in 32 ; inductions 
of premature labor, 2; convulsions, 13; hemorrhages, 35 ; ruptura 
uteri spontanea, 2 ; forceps operations, 43 ; perforation, 5 ; Caesarian 
operation post-mortem, 1 ; artificial removal of the after-birth, 15 ; 
diseases of the puerperal state, 182 ; deaths, 83. 

From Dr. J. B. Schmidt's report we give the following facts of 8t9 
births ; 869 were simple, and 10 twin-births ; 839 children born alive, 
50 dead : 

I. Cranial presentation 606 

IL " « 231 

I. Facial " 1 

II. « " 3 

I. Breech " 12 

II. " * " 6 

Atonic pains were observed in 42 cases, and treated with the col- 
peurynter, the .douche, carbonic acid, or ergot of rye ; spasmodic 
pains, 24 ; treatment : opium, tepid baths, chloroform, colpeurynter 
and douche ; ruptures of the perineum, 18, three being to the sphinc- 
ter ani ; to prevent perineal ruptures, the labia were incised 85 times ; 
pelvic deformities 15, t delivered naturally, 3 with the forceps, 2 by 
perforations and cephalotripsis, 1 by extraction on one foot, 2 by 
induction of premature confinement. Eclampsia observed in 1 case, 
chloroform used, mother died suddenly. Placenta praevia partialis, 
3 cases, colpeurynter, opening of the membranes ; plac. pr. central., 
1 case, turning and extraction of the child ; three mothers recovered 
— one died afterwards from puerperal fever — 2 children born alive, 2 
dead. Prolapsus of the funis, 11, 6 with cranial presentations. In- 
duction of premature labor was performed 3 times. Case 1. — Hydre- 
mia, catarrh of the kidneys, dyspnoea ; application of sucking-glasses 
to the breast nine times in three day, inefficient pains ; douche twice 
a day for a week, insufficient pains ; injections with secale cornutum, 
strong pains, os dilated to the size of a gulden ; membranes detached 
with the sound, two hours afterwards birth of a dead child weighing 
2| pounds ; mother recovered. Case 2. — Pelvic contraction, antero- 
posterior diameter 3| to 3£, induction of premature labor by six ap- 
plications of carbonic acid to the vaginal portion in five days ; child 
born alive, mother recovered. Case 3. — Contracted pelvis, sucking- 
glasses, douche, colpeurynter, all without exciting labor pains ; tap- 
ping of the membranes ; cross presentat'on, turning ; child dead, 



Feet presentation 6 

Cross " 18 

Uncertain " 11 

889 



125 

mother recovered. Case 4. — Contracted pelvis, carbonic acid gas, 
injection of decoctum altheese, plugging of the vagina (Shoeller,) 
opening of the membranes (Meissner's method) ; child born dead, in 
foot presentation ; mother recovered after being taken with endome- 
tritis. Forceps operation 47, all mothers recovered except one, who 
died from puerperal fever ; 42 children born alive, 5 dead. Crani- 
otomy 2, both from contracted pelvis ; one mother died from endome- 
tritis and pyaemia. 

From Dr. Gregor Schmidt's report it appears that during the six 
years from 1850 to 1856, 1,639 women were delivered in the lying-in 
hospital, and among this number 21 twin births were observed, mak- 
ing a total of 1,666 children, of which 1,536 were born alive, 130 still- 
born ; 113 of the children born alive died afterwards in the hospital. 

Breech presentations 25 

Feet " 23 



I. Cranial presentations 1109 

II. " " 443 

I. Facial " 6 

II. " " 4 



Cross " 24 

Uncertain " 26 



Operations : 1. Inductions of premature labor, 6 ; mothers recov- 
ered, 6 ; children born alive, 3 ; dead, 3. 2. Forceps operations, 100 ; 
mothers recovered, 94 ; died, 6 ; children born alive, 80 ; dead, 20. 
3. Extractions, 39 ; all mothers recovered ; children born alive, 26 ; 
dead, 13. 4. Turning by one foot, 24 ; mothers recovered, 22 ; died, 
2 ; children born alive, 12 ; dead, 12. 5. Craniotomy, 5 ; mothers 
recovered, 4 ; died, 1 ; operation with Van Huevel's forceps-scie., 1 ; 
mother recovered. 

Dr. Holston's report discusses in separate chapters the history of 
midwifery in Ohio ; its theory and practice, comprising a considera- 
tion of " the frequency of midwifery" and natural labor ; tedious and 
difficult labors, more particularly in reference to ergot as a remedial 
agent ; statistics of natural and preternatural labors ; the diseases 
of puerperal women ; and obstetrical literature and education. 

Dr. McMeen's report on uterine diseases, consists chiefly of an ac- 
count of four interesting cases. One of hypertrophy of the womb, 
with excessive flow of the catamenia — mistaken for a case of poly- 
pus uteri. The second case is one of intractable dysmenorrhcea. 
The third case is one of intense hysteralgia excited by the use of 
ergot taken with a view to the production of abortion ; while the 
fourth is one of extensive vesico-vaginal fistula, caused by malprac- 
tice in a resort to instrumental interference, merely to gain time. 



II.— ANATOMY AND PHYSIOLOGY OF THE UTERUS 
AND OVARIES. 

1. ./Cran, F. A., Anatomical and ' Anatomo-pathological Researches on the 
" Staiique" of the Uterus. — Archiv. Gdndr., Feb. and March. N. Y. 

Jour, of Med. VI. 1. July. 

2. Guyon, F., Etudes sur les coxitis de Vuterus a Vitat de vacuiti. These. 
Paris, Mars, 1858. 

— Guyon, F., on the Condition of the non-Pregnant Uterine Cavities, etc. 
Thesis — N. Y. Jour, of Med., V. 3, November. 



126 

3. Dumas, on the Uterus and Ovaries of a Virgin, who died a few days 
after Menstruation. — Rev. therap du mid. xi. p. 293. 

4. Priestly, W. 0., Lectures on the Development of the Gravid Uterus. — 
Delivered at the Grosvenor Place School of Medicine. Med. Times 
and Gaz., 438, Nov. 20, etc. 

5. Robin, Ch., Memoir on some Points connected with the Anatomy and 
Physiology of the Mucous Membrane, and the Epithelium of the Uterus 
during Pregnancy. Brown Sequard's Jour, de Physiol., January, 
and New Orleans Med. News and Hosp. Gaz., July and August. 

6. Dalton, S. C, on the Anatomy of the Placenta. — Amer. Med. Monthly, 
July. N. Y. Jour, of Med. v. 3, Nov. 

?. Luschka, on the Liquid Portion of the Graafian Follicle. Wurtemb. 
Naturw. Jahresh. Jahrg. 13. N. Y. Jour, of Med. V., 1 July. 

8. Uterus and Us Appendages. By Dr. Arthur Farre, London, 1858. 

9. Beale, Liquor Amnii containing much Urea. Archives of Med. No. II. 

10. Hilly er, E., an Essay on the Physiology of Menstruation. South. 
Med. and Surg. Jour, xiv., 12, Dec. 

11. Spiegelberg, 0., on the Nervous Centres and the Motion of tlie Uterus: 
— Henle and Pfeuffer, Ztschr. 2. N. Y. Jour, of Med. v. 1 July. 

12. Savory, W. T., an Experimental Inquiry into the Effect upon the Mother 
of Poisoning the Fcetus. — Lancet, June. N. Y. Jour, of Med. v. 2 Sept. 

13. Giraudet, E., on the Value of the Current Theories for the Explica- 
tion of the Causes of Menstruation. — Gaz. des Hop., June 15. 

14. Kirsten, Th., on Glycosuria Lactantium. Monatschrft f. Geb. ix. 6. 
N. Y. Jour, of Med. iv. 3. May. 

15. Riedel, on Glycosuria in Pregnant and Parturient Women. — Monat- 
schrft f. Geb. x. 2. N. Y. Jour, of Med. iv. 3. May. 

16. Biiicke, on Glycosuria of Women in Child-bed. — Wien. Med. Wo 
chenschrft. 19, 20. 

IT. Hewitt, G., on Coagula Formed in the Veins during the Puerperal 
State. — Lancet, April. 

18. Savage, on the Erectile and Venous Systems of the Pelvic Organs. 
Lancet, Feb. N. Y. Jour. iv. 3. May. 

19. Rouget, Ch., on the Female Erectile Organs, and on the Tubo-Ovarian 
Muscular Apparatus in its Connection with Ovulation and Menstruation. 
Jour, de Physiologie, etc., No. 2, 3, 4. 

20. Lee, R., on the Membrana Decidua which surrounds the Ovum in 
Cases of Tubal Gestation. — Lancet 1, April. 

By far the most valuable contributions to obstetric anatomy and 
physiology, which we have received from France, are Dr. Rouget's 
article on the erectile organs of the female, and Dr. Aran's statisti- 
cal researches on the " statique " of the uterus. They are replete with 
new ideas and scientific researches. Next to these, we place Dr. Dal- 
ton's article on the anatomy of the placenta, who by one bold experi- 
ment seems to have decided the question with regard to the manner in 
which the foetal part of the placenta is connected to that of the mother. 

Under the name statique of the uterus, Dr. Aran comprises its sit- 



127 

uation as far as it is established by its anatomical condition, and as 
far as it is liable to be changed by different circumstances. Think- 
ing that even now the discussion in regard to this subject had by no 
means come to a satisfactory result, the author intends to review the 
opinions current, and to add new observations and opinions of his 
own. Of the different ligaments believed to sustain the uterus in its 
position (two lateral, one anterior, one posterior — plicae Douglasii), 
he thinks the latter alone deserve the title of ligament, because of 
their fibrous texture. His inquiries in regard to these structures 
differ somewhat from the description given of them by the most re- 
liable anatomists : 1. It is not the inferior portion of the uterine 
neck from which they start, but from the point where the collum and 
corpus uteri meet. 2. Instead of two ligaments there exists in re- 
ality but one, because the inner and posterior fibres form but one 
continued layer, without any line of demarcation, while the middle 
strata cross each other in the median line, and the external bundles 
are mixed up on each side with the uterine tissue itself. 3. These 
ligaments do not always surround the cavum recto-vaginale, i.e., they 
do not comprise in every instance the rectum in their posterior de- 
partment. 4. They do not stop in the middle portion of the pelvis, 
but extend their ramifications as high as the fourth, and sometimes 
the fifth, lumbar vertebra. Moreover, the direction of the posterior 
ligament is not from below upwards, but it runs in the opposite di- 
rection ; nor does it extend in one straight line from the uterus to 
the sacrum, but near the latter point it spreads outwards. Therefore 
its influence upon the position of the uterus is to prevent descent 
towards the outlet of the pelvis, retaining it over the neck near the 
os sacrum. These ligaments almost disappear during pregnancy, 
while they exhibit an enormous state of hypertrophy when the uterus 
is retroverted. The ligamenta rotunda are not intended to keep the 
uterus in its elevated position, but merely prevent the fundus from 
falling backwards ; therefore the operation of shortening the round 
ligaments, as proposed by Dr. Alquid for curing prolapsus uteri, 
would prove a failure. Notwithstanding Dr. Stoltz's experiment, 
who removed the entire vagina without producing an alteration in 
the position of the womb, it seems probable that the vagina has some 
influence in retaining the uterus in its position, as is proven by the 
good result following artificial constriction of the vagina for the pur- 
pose of curing the falling of the womb. Dr. Aran, far from under- 
rating the importance of the vesico-uterine ligament as a means of 
influencing the position of the uterus, cannot agree entirely with 
Prof. Virchow's views, who seems to consider the adherence of 
the uterus with the bladder to be one of the chief points of its sup- 
port. The conclusions drawn from these remarks are as follows : 1st. 
The uterus is suspended in the pelvic cavity of the adult female by 
a complet of different means of suspension, composed of the inser- 
tions of the bladder and vagina in front, of the vagina and the posterior 
ligaments in the rear, and laterally of the vagina and the lateral 
fibres of the posterior ligament. 2d. The combination of these means 
of suspension establishes a real axis — "axede suspension" — around 
which the movements of the uterus are completed. The relation of 



128 

the uterus to this "axe de suspension," is not yet fully ascertained. 
In following the natural development of the uterus from the very first 
months of existence, it is an acknowledged fact, that in foetal life 
the body of the womb is always somewhat bent upon its neck, which 
flexion disappears the more the female advances in years, and above 
all it is the pregnant state which corrects this flexion of the uterino 
body. Dr. Gosselin found, in forty-eight post-mortem examinations 
of women who had never been pregnant, twenty-seven more or less 
decided anteflexions of the womb, eighteen perfectly straight, and 
three dubious cases. Dr. Aran found, among nine young virgin fe- 
males, from 11 to 2? years of age, six decided anteflexions, two re- 
troversions, and one straight uterus ; of ten married sterile women, 
there were six below 24 years of age with decided anteflexions, two 
with anteversions (one of them 48, one 49 years old), two with an 
almost straight uterus (18 and 55 years old); of twenty-one women 
who had borne children, seven exhibited unmistakable anteflexion 
(2a to 27 years old), three presented a slight inclination in front (33, 
40, and 51 years old), two showed retroversion (age, 28 to 40 years), 
in four the axis of the uterus followed that of the upper pelvis (ages, 
26, 28, 33, and 44), in five cases the womb was retroverted (age, 22, 
25, 40, 44, 45). In all of these cases no traces of uterine disease had 
been exhibited during life. This shows that 50 per cent, of the ex- 
amined (post-mortem) women had an anteflexed womb, the cases 
belonging almost exclusively to young women and those who had 
never borne children. Therefore, in childhood and puberty the axis 
of the womb does not follow the axis of the upper pelvis, but is more 
or less inclined in front, which disappears the more the woman ad- 
vances in years, and after she has been pregnant. In regard to Dr. 
Cruveilhier's opinion, that the axis of the uterus in the living female 
changes with the position of the body, Dr. Aran thinks that this state 
of indifferent axis is not the rule, but the exception, it being only 
met with in those cases where the means of suspension around the 
uterus are in a state of weakness, such as occur in consequence of 
repeated confinements. One thing is certain, that the uterus of 
healthy females may be found, in anteflexion or forward inclinations, 
quite straight, and in the direction of the upper pelvis, or in an indif- 
ferent position, following simply the laws of gravitation. The foetal 
anteflexion of the uterus, Dr. Aran considers to be the result of the 
pressure of the abdominal viscera upon the extremely soft and flexi- 
ble body of this organ. In more advanced age, the walls of the body 
of the uterus thickening, and the point of union between body and 
neck settling lower down, the condition favoring a state of anteflex- 
ion, disappears. In those cases where anteflexion remains: after the 
years of puberty, and, what is very rare, after pregnancy, the short- 
ening of the round ligaments may be accounted for, in consequence 
of which the uterus is unable to be sufficiently thrown backwards 
by the bladder when filled with urine. There are two kinds of uterine 
obliqity ; in the first instance the fleck remains in its position, while 
the body is bent upon it towards the right or left side ; in the second 
instance, one of the superior corners of the uterus is drawn upwards 
and in front, the other side of the womb being placed in the opposite 



129 

direction ; so in both cases the corresponding round ligament, and 
generally the utero-sacral ligament, are shortened. The greatest 
difference between the two round ligaments, as observed by Dr. Aran, 
was 95 mm . ; the greatest number of these lateral inclinations is found 
among children, which condition seems to disappear as they advance 
in years. From these researches it appears that it is wrong to con- 
sider and treat anterior and lateral inflexions in young females, as 
pathological conditions, especially if they do not give rise to dys- 
menorrhoea or sterility, in more advanced years. 

Dr. Guyon applied a stiffening substance for injecting the uterus, 
in order to find out the shape and dimensions of its cavity at the dif- 
ferent stages of life. The results obtained in this way may be com- 
prised as follows : 

1. From birth to the time of puberty. — The axes of the arbor vitse are 
greatly developed, especially towards the upper extremity of the 
neck, so as to form an isthmus almost obliterating the cavity, from 
whence they diminish rapidly in size, ramifying towards the cavity 
of the body. A cavity of the womb does not exist, properly speak- 
ing, because the elevations of its internal surface touch each other 
entirely. The shape of the cavity is such, that it shows at its lower 
end a larger size, while from this point it contracts gradually up to 
the fundus, where the intertubular diameter is smaller than that of 
the entrance. The cavity of the body measures a little less than 
one-fourth of the entire length of the organ. 

2. Virgin and nulliparous uterus. — The cavity of the body appears 
to be divided in two sections, one starting from the neck, narrow 
and long, the other intertubular, formed by two trigons connected at 
their basis. The three sides of the cavity are convex ; the lateral 
ones at first very obliquely directed, suddenly change their direction, 
approaching a vertical line on the summit of this second portion of 
the body. 

The cavity of the neck is only a few millimetres larger than it 
was immediately after birth ; it is enlarged somewhat in the middle, 
restricted at the entrance, and not changed at its upper extremity. 
The shape of the mouth is generally that of a transverse slit, and 
not circular. The lateral columns present the same elevation as in 
the foetus, in consequence of which the internal orifice is closed up 
by the natural rigidity of the uterine tissue. The folds representing 
the branches of the arbor vitae are arranged in such a way that 
their free edge looks towards the orifice, so that they may arrest in 
some instances the entrance of a probe. In virgins, the length of 
the cavity of the neck exceeds that of the body, notwithstanding the 
latter one has considerably increased. In women who are used, to 
sexual intercourse, the difference of both cavities is null, or a trifling 
increase of the cavity of the body. 

The isthmus represents a cylinder of 5 or 6 mm in length, measur- 
ing 4 mm in its transverse, and 3 mM in its antero-posterior diameter. 
The total capacity of the cavities is from 3 to 5o em . 

3. Muliiparous uterus. — Cavity of the body perfectly triangular, in- 
closed within convex lines, but less so than in the virgin uterus, so 
that the uterine horns are enlarged at the expense of the iater- 

9 



130 

mediate cavity. The vertical, as well as the lateral diameters are 
increased, while the cavity of the neck is larger, but shortened, 
owing to the contraction of the vaginal portion. 

The internal orifice (isthmus) is wider and shortened, but always 
closed by the projections of the walls, and the arbor vitse continues 
to be perceptible. The capacity of the cavities is from 5 to &zP m . 

4. Uterus at the change of life. — The internal orifice is generally 
obliterated. The cavity of .the body, more or less distended by a 
transparent mucus, has generally retained its shape, and has gained 
a few millimetres in hight. The neck has decreased in length, so 
much so that, as a general rule, the vaginal portion has disappeared. 
After the external orifice is closed up in old women, the cavity of 
the womb exceeds in length that of the neck from 10 to 12 mm j in 
multiparous females, 0.004 mm ; in nulliparous women, who have had 
sexual intercourse, both cavities are almost equal in length ; in 
virgins, the cavity of the neck is 0.003 mm longer than that of the 
body, and 0.006 mM in the foetus. From these researches, the author 
concludes that the uterine constrictions are always seated in the 
isthmus, and that they may result from a flexion, and more especially 
from retroflexions with rotation. The penetration into the perito- 
neum of intra-uterine injections, though manageable after death, is 
prevented in the living female by contractions of the womb. 

Dr. Robin remarks that most modern authors are of opinion that 
the membrana decidua serotina (m. caduca inter-utero-placentaris) 
is discharged with the placenta, like the rest of the decidua with the 
chorion. This is not exact, nor is it quite true that the placentar 
villosities are imbedded in the serotinous sinuses, like t roots of 
plants in the soil. The inter-utero-placentar membrana caduca is 
that portion of the uterine mucous membrane, at the level of which 
the chorial villosities are hypertrophying for forming the placenta. 
While the rest of the mucous membrane atrophies as membrana 
caduca, this portion, in connection with the placenta, remains in a 
state of great vascularity, °* Its enormous venous sacs are in direct 
communication with the venous sinuses of the muscular layer. These 
enlarged veines are in communication with the circular sinus of the 
placenta, which is, in fact, not&'ng but one or more of the serotinous 
veines. If a woman is delivered in her seventh or ninth month, the 
membrana caduca vera and-reflecta are entirely removed, but only 
half of the serotinous caduqa, because its sinuses are found divided 
nearly in their midst, whil£ the greatest portion remains attached to 
the uterus. 

The uterine surface of the placenta, when removed at the full term, 
is .covered with a thin, greyish membrane, of \ or 2 mm . This mem- 
brane is unquestionably nothing but the thickened epithelium of the 
inter-utero-placentar mucous membrane of the uterus, and the most 
superficial portion of the mucous membrane. Its microscopical 
elements are hypertrophied epithelial cells, an amorphous substance, 
molecular granulations, etc. This fact was first noticed by the 
author of this article. Therefore, the placentar villosities are sepa- 
rated from the serotinous sinuses by interposition of this thin mem- 
brane, and the contact of the foetal blood with that of the mother is 



131 

by no means a direct one. The same disposition has been observed 
in a great number of different classes of animals, viz., that the vas- 
cular system of the foetus is only connected with that of the mother 
by juxtaposition. That portion of the uterus where the placenta was 
located, is covered with the serotina, even after the detachment of 
the placenta, with the exception of that thin superficial layer which 
adheres to the placenta. This remaining portion of the uterine 
mucous membrane is not exfoliated, its vessels being in immediate 
connection with those of the muscular stratum, and, therefore, a 
fresh mucous membrane is not formed between the serotina and the 
uterine muscularis, as it exists between the latter and the uterine 
caduca. The serotinous membrane of a woman, who dies in the 
seventh or ninth month of gestation, presents an aspect very different 
from that of a woman who dies two or ten days after confinement. 
In the former instance it is soft, as large as the placenta ; the sinu- 
ses are flattened ; their long diameter prevailing ; its surface is 
slightly wrinkled, but comparatively even. After confinement the 
serotinous surface becomes much smaller from the contraction of the 
uterine walls ; its form, instead of being circular, is irregularly 
oval, with a sinuous, incised border ; it is a thick, folded, rough 
membrane ; its surface becomes after a while softened, and of a 
mucous consistency. The irregular edges of this serotina are found, 
a few days after confinement, to enter into connection with the soft, 
new mucous membrane which lines the rest of the uterus. This red- 
dish, irregular, flocculent appearance of the serotina has often led to 
mistakes, as it was taken for a portion of the adherent foetal pla- 
centa, in cases of death after puerperal fever. Several days after 
confinement, this remaining portion of the inte/-utero-placentar 
caducous membrane is diminished in size and thickness ; it begins 
to soften and decay, to be replaced by a new mucous membrane. 

While the epithelium of the uterine cervix retains its cylindric 
character throughout the time of gestation, that of the cavity of the 
womb passes gradually from the cylindric into the pavement form. 
This phenomenon must not be understood to be a strict transforma- 
tion of one into another form, but it is rather an exfoliation of the 
old cylindric cells, which are replaced by new epithelial cells of the 
plated variety. But the most remarkable change is observed in 
those epithelial cells which are placed between the placenta, and the 
vascular portion of the uterine mucous membrane (m. caduca inter- 
utero-placentaris). They are not only hypertrophied, but also 
deformed, being A mm in length, instead of T lir mm « The greatest 
number of these deformed cells are lengthened, terminating in one 
or two irregular points. One or both of these cellular extremities are 
found irregularly bifurcated. Some of these hypertrophied cells 
contain two or three nuclei, some only one, and every nucleus has 
inclosed one or two nucleoli. Besides these cellular formations, may 
be observed nuclei, very much like those described as cancer- 
ous or carcinomatous nuclei. Some of the hypertrophied cells re- 
main as they were in the normal state — finely granulated and trans- 
parent, while others are filled with fatty molecules, with a brilliant, 
yellow centre. Similar transformations are found in the epithelial 
cells of the uterus in domestic mammalias. 



132 

Dr. Dalton, after entering briefly into the historical part of the 
utero-placental anatomy, proceeds to develop his views on the distri- 
bution of the uterine vessels, with regard to those of the placenta. 
In opposition to Dr. Robin's views, he holds that the blood-vessels of 
the uterus do really penetrate into the substance of the placenta, as 
supposed by the Hunters, Dr. Reid, and Prof. Goodsir, and that they 
constitute, with the tufts of the foetal chorion, an equal part of its 
mass. The placenta is therefore a double organ, partly maternal 
and partly foetal, and in order to arrive at a distinct understanding 
of the arrangement of its vessels, a description of the development 
of the chorion of the foetus and of the decidual membrane of the uter- 
us, is necessary. At first, the villi of the chorion are quite simple in 
form and homogeneous in structure. Afterwards they become ram- 
ified by the repeated budding of lateral off-shoots from every part, 
and the external surface of the chorion presents a velvety appear- 
ance. Under the microscope these tufts appear to terminate by 
rounded extremities, and the larger branches of the villosity are seen 
to contain numerous oval nuclei, imbedded in a nearly oval homoge- 
neous stratum, while the smaller villosities appear simply granular 
in texture. The blood-vessels coming from the umbilical arteries 
ramify over the chorion, and penetrate into the substance of the vil- 
losities. They enter the stem of each tuft, and following every divi- 
sion of its compound ramification, they reach at last its rounded 
extremities. Here they turn upon themselves in loops, to unite 
finally with the venous branches which empty into the umbilical 
vein. About the third month the chorion becomes partially smooth. 
This smoothness, which begins at a point opposite the situation of 
the foetus, increases in extent, and becomes more and more complete, 
spreading and advancing over the adjacent portions of the chorion. 
At the opposite portion of the egg, the chorion is thickened and 
shaggy, and takes part in the formation of the placenta, while the 
umbilical arteries enter the villi, forming at the placental portion of 
the chorion, a mass of ramified vascular loops. 

The decidua is nothing more than the mucous membrane of the 
body of the uterus. It consists throughout of minute glandular tu- 
bules, ranged side by side. A few fine blood-vessels penetrate the 
mucous membrane from below, and encircle the superficial extrem- 
ities of the tubules with a capillary network. A small quantity of 
spindle-shaped fibro-plastic fibres is scattered between the tubules. 
The egg, when descended into the cavity of the womb, is embedded 
in this hypertrophied membrane, and becomes attached to it. The 
villosities of the chorion insinuate themselves either into the uterine 
tubules or between the folds of the decidual surface. In this way 
the egg becomes entangled with both decidua reflexa and vera, 
throughout the whole surface. Soon afterwards the umbilical ves- 
sels penetrate everywhere into the villosities of the chorion. Each 
villosity of the chorion, then, as it lies embedded in its uterine fol- 
licle, contains a vascular loop, through which the foetal blood circu- 
lates. At a later stage the vascular growth, both of chorion and 
decidua, becomes concentrated at the situation of the subsequent 
placenta, while elsewhere, over the prominent portion of the egg, the 



133 

chorion not only becomes bare of villosities, but the decidua reflexa 
also loses its activity of growth, and becomes expanded into a thin 
layer, nearly destitute of vessels. 

The placenta, accordingly, is formed by the continued growth at 
one particular spot of the^villi and follicles of the decidua. The uter- 
ine follicle enlarges with the villus, which has penetrated into it, 
sending out branching diverticula, Besides the follicles of the uter- 
ine mucous membrane, also the capillary blood-vessels, which lie 
between them, become unusually developed. At this time, therefore, 
each vasculsr loop of the foetal chorion is covered first with a layer 
forming the wall of the villus, which is in contact with the lining 
membrane of the uterine follicle ; and outside of this again are the 
capillary vessels of the uterine mucous membrane, so that two dis- 
tinct -membranes intervene between both the foetal and the maternal 
capillaries. As the formation of the placenta advances, the general 
anatomical arrangement of the foetal vessels remains the same. But 
the maternal capillaries become considerably altered ; they enlarge 
excessively and fuse successively with each other, thus becoming 
dilated into wide sinuses. At this period the development of the 
blood-vessels, both in the foetal and maternal portions of the placenta, 
becomes so extensive, that all the other tissues, which originally co- 
existed with them, fall into a retrograde condition and disappear al- 
most altogether. The villosities of the chorion are now hardly any- 
thing more than ramified vascular loops, while the uterine follicles 
have become mere vascular sinuses, into which the tufted foetal 
blood-vessels project. Finally, the walls of the foetal blood-vessels 
having come into close contact with those of the maternal sinuses, 
become adherent to them, and fuse with their substance, so that the 
two can no longer be separated without lacerating either the one or 
the other. The placenta, at this stage, is composed essentially of 
nothing but blood-vessels of the foetus adherent to the blood-vessels 
of the mother ; the blood of the foetus is always separated from the 
blood of the mother, which has resulted from the fusion of four differ- 
ent membranes, viz. : the membrane of the foetal villus ; that of the 
uterine follicle ; the wall of the foetal blood-vessels ; the wall of the 
uterine sinus. If a villus, from the foetal portion of the placenta, 
be examined, it will be seen that its blood-vessels are covered with 
a layer of homogeneous or finely granular material, 3 B Vo of an inch 
in thickness, in which are embedded small oval-shaped nuclei. This 
layer is all that intervenes between the foetal blood in the tufts of the 
chorion, and the maternal blood in the placentar sinuses. The ana- 
tomical disposition of the placentar sinuses is very difficult of exam- 
ination in the detached placenta, because they are collapsed and 
apparently obliterated, and the foetal tufts appear to constitute the 
whole of the placental mass ; still they may be satisfactorily dem- 
onstrated in the following manner. The uterus of a woman who had 
died undelivered, near the full term, is opened so as not to wound 
the placenta ; then, after the foetus is removed, it is placed under 
water, with its internal surface uppermost. Then the amnion has to 
be removed from the placenta. If the end of a blowpipe be now in- 
troduced into one of the divided vessels of the muscular walls of the 



134 

uterus, and air forced in, wo can easily inflate, first the venous sin- 
uses of the uterus itself, and next the deeper portions of the placenta. 
If the chorion be now divided at any point by an incision, passing 
merely through its thicknea, the air which was confined in the pla- 
cental sinuses will escape and rise in bubbles to the surface of the 
water. Such an experiment shows conclusively that the placental 
sinuses communicate freely with the uterine vessels, occupy the en- 
tire thickness of the placenta, and are equally extensive with the 
tuft of the foetal chorion. This experiment has been performed by 
Dr. Dalton on four different occasions. This method has many ad- 
vantages over that adopted by the Hunters and Prof. Weber, espe- 
cially because it is infinitely less liable to mislead by producing 
extravasations. 

The opinion of some authorities, that no vascular openings are to 
be seen on the surface of the detached placenta, corresponding with 
the mouths of the lacerated uterine sinuses, is explained by the fact 
that these vessels penetrate in such an extremely oblique direction, 
that their orifices may easily be overlooked. 

Dr. Ldschka remarks that the walls of a follicle consist, first, of 
a membrane abundantly imbued with blood-vessels, the stroma of 
which is a cellular tissue with elastic fibres, and which is separated 
from the inner epithelium by an amorphous membrane, being at- 
tached externally to the stroma of the ovarium by a thin cellular tis- 
sue : secondly, of the epithelium — this consists of a great quantity 
of round or angular cells in the different stages of development ; 
they represent what is called the stratum granulosum. These cells 
are most numerous on that portion of the sac, where the ovulum is 
situated, which they surround on all sides, so that here a protrusion 
is formed into the cavity of the follicle, generally called cumulus 
proligerous. 

The rest of the Graafian follicle is filled up by a yellowish, albu- 
minous fluid — the liquor folliculi Graafiani. This liquor takes its 
origin from the cells of the stratum granulosum, as can be proven 
by microscopical examination of the different stages of development 
of these cells. First of all a nucleus is formed out of the blastema of 
the blood, around which molecular matter is deposited, and from 
which the amorphous wall and the contents of the cell are separated. 

The most superficial ones are the most developed. Their gran- 
ular contents are changed into a clear albuminous substance, 
from which the cells become larger and pellucid. These fluid 
contents pass through the walls of the cell in the shape of clear 
oily drops, which disolve after some time in water. In this case the 
cellular wall contracts, to be filled anew. In other instances the en- 
tire cell is dissolved, without leaving any trace, or with continuance 
of the nucleus, which serves for the formation of a new cell. But, 
not every one of the cells participates in the formation of the liquor, 
some passing into fatty degeneration, some undergoing no change 
whatever. This fluid is the original blastema from which the ovu- 
lum originated ; it further serves as nourishment while the ovum is 
being developed ; and lastly, being increased by direct extravasation 
from the congested blood-vessels during the catamenia, it expands 



135 

and finally ruptures the Graafian follicle. The ovum thus set free 
has to subsist for some days on its own means ; for this purpose it 
takes along a certain number of those cells which cover it, in the 
form of what is generally called discus proligerous. 

Dr. Farre's treatise on the uterus and its appendages is an import- 
ant contribution to the anatomy, physiology, genesis, and patho- 
logical anatomy of the entire sexual apparatus, with an additional 
article on the structure and function of the placenta. The amount of 
researches and facts laid down in these pages is so great, that we 
must abstain from giving an abstract, recommending the work to 
every one who takes ^in interest in the study of anatomy and physi- 
ology of the female genitals. 

Dr. Beale relates a case of a patient in the eighth month of preg- 
nancy, from whom about seven pints of liquor amnii were drawn 
off. The specific gravity was 1,006. The deposit was flocculent, 
and consisted principally of epithelial cells and oil globules from 
the surface of the skin of the foetus. A few circular cells, probably 
derived from the bladder, and some particles of dark green, and 
brown coloring matter (meconium), were also present. The follow- 
ing was the result of the analysis : 

Water ,981.00 

Solid matter 13.00 

Urea 3.50 

Albumen and salts 9.50 

In another case, Dr. Beale found in liquor amnii, drawn from a 
woman in the eighth month, a number of coats of uriniferous tubes, 
scarcely half the diameter of those found in the adult. 

An analysis of a great number of experiments upon forty living 
animals, in order to answer the question, What are the causes and 
the seat of uterine movements ? led Dr. Spiegelberg to the following 
conclusions : 1. The stoppage of the circulation, and consequent 
stasis of blood, is the cause of the peristaltic movements of the uterus. 
As long as the heart is in activity, there are no movements seen at 
all, or they are very trifling. 2. Through the nervi vagi no excita- 
tions are conducted to the uterus. 3. By irritation of the medulla 
oblongata, uterine movements can be effected. 4. The cerebellum 
is the nervous centre which chiefly controls the movements. 5. 
From every point of the spinal cord, but more especially from its 
lumbar and sacral portions, movements of the uterus can be pro- 
duced. 6. The expitations starting from the central organs travel 
downwards along the medulla oblongata and the spinal cord, and 
proceed through the rami communicantes of the sympathetic, and 
through the sacral nerves to the uterus ; and likewise excitations 
rising from the uterus are produced through the same channel. As 
to the order in which the utei'ine contractions follow, Dr. S. believes 
from his experiments, that first of all the mesometrium begins to 
contract, in consequence of which the uterus is fixed towards the pel- 
vis ; after this the vagina and the cervix uteri contract ; this circu- 
lar contraction proceeds up to the fundus uteri, and from thence 
returning, presses the foetus downwards, while the cervix and vagina 
are enlarged. 



136 

Dr. Savory remarks, that although the question as to the possibil- 
ity of transmitting poisons through the foetal vessels of the cord to 
the maternal blood, seemed to be settled in the negative by the ex- 
periments of Magendie, many physiologists still believe, that the 
foetal blood commingles with the general mass of the mother's blood ; 
it inoculates her system with the qualities of the foetus ; and that, as 
these qualities are in part derived by the foetus from its male pro- 
genitor, the peculiar constitutional vices of the latter are thereby so 
engrafted on the system of the fertfale, as to be communicable by her 
to any Offspring she may subsequently have by other males. And 
as, moreover, the nature of Magendie's experiments appeared to Dr. 
Savory objectionable, he followed another method, which was 
crowned with affirmative results. His general plan was as fol- 
lows : By opening the abdomen and uterus to expose and isolate a 
living foetus ; then to inject into it, with the least possible violence, 
some substance capable of ready absorption, and the operation of 
which is marked by obvious and unmistakable effects, great care 
being taken that no trace of the substance came into direct contact 
with the maternal tissues. The foetus, thus injected, was placed in 
a condition most favorable for the continuance of the circulation, and 
symptoms of the operation of the poison upon the mother were care- 
fully noted. The poison Dr. Savory selected was twenty-four grains 
of strychnia; dissolved in seven drachms of distilled water, by the 
addition of one drachm of acetic acid. The subjects of his experi- 
ments were dogs, cats, and rabbits. Five experiments are reported, 
from which it seems that proof is no longer wanting, of the direct 
and rapid transmission of matter from the foetus to the mother 
through the blood in the placenta. 

Dr. Kirsten detected the presence of sugar in the urine of 
women in childbed, especially in those cases where lactation had 
been interrupted. He examined some specimens from women, where 
puerperal fever had cut short the secretion of milk, or where the 
children had died soon after birth. The method he used for ascer- 
taining the presence of sugar was, by reduction of the oxide of cop- 
per through the watery solution of the alcoholic extract of the urine. 

For testing the truth of Dr. Blot's observation, according to which 
sugar was a natural ingredient of the urine of women in childbed 
and when pregnant, Dr. Riedel examined the urine of eleven women 
in childbed, two of whom had lost their children, and three pregnant 
women. In none of these fourteen cases was he able to detect the 
slightest traces of sugar after Trommer's test. 

In order to ascertain whether sugar was a constant ingredient of 
urine taken from women in child-bed, Dr. Brucke tested it on a new 
principle, viz. : by formation of acetate of sugar, because the other 
methods hitherto employed seemed to be of doubtful value. In this 
way he detected considerable quantities of sugar in the tested urine. 
Still it remains to determine if similar quantities of sugar may not 
be detected in the urine of healthy men or non-pregnant women. 
Without having performed quantitative analysis, Prof. Brucke is al- 
ready satisfied that the increase of sugar of healthy women after 
delivery is by no means a constant and general phenomenon. 



137 

Dr. Graily Hewitt remarks that the circumstances preceding or 
necessarily connected with the act of parturition, which may lead to, 
or favor the formation of coagula within the veins, are to be found 
1. In the state of the. blood during pregnancy. Its amount of fibrin is 
increased, the number of blood-corpuscula and the quantity of albu- 
men diminished. This hyperinotic state of the blood of pregnant 
women predisposes to the occurrence of those puerperal affections of 
which the so-called phlebitis forms a constituent part, in which co- 
agulation of the blood in the veins is the starting point. On the 
other hand, women who suffer in a great measure from diminution 
of red corpuscula (chlorotic women) are very liable to puerperal 
fever (Scanzoni). 2. Another cause for coagulating the blood is to be 
found in the mechanical effects of the pressure of the enlarged uterus, in 
consequence of which disturbance of the circulation, favoring stasis 
of the blood in certain veins, is often observed. 3. The influence of 
pressure during the act of parturition, as performed by the head of the 
child resting for a considerable time on the brim of the pelvis, in 
such a position as to retard the venous current, passing from the 
pelvic organs and lower extremities, be it by protracted labor or by 
a misproportion of head and pelvis. 4. Deficient contraction of the 
uterus and of the venous plexuses near it, after delivery. If the uterus 
does not contract sufficiently after delivery, the blood contained in 
the large sinuses stagnates, and a tendency to coagulation of 
the contents of the vessels is produced. 5. The existence of physi- 
ological coagula. The formation of these coagula in the orifices of the 
uterine veins is favored by two circumstances ; there is a stasis of 
blood within the veins, and in many cases exposure of the same to 
the action of the air. The existence of these normal coagula has no 
small share in forming the coagulations in the large veins of the pel- 
vis, and parts adjacent to the uterus (Virchow). 6. The occurrence of 
hemorrhage after parturition, because it interferes with the perfect 
involution of the uterus, or when successfully arrested, after some 
time, the coagula are loose and less consistent, thus favoring the ad- 
mittance with the circulating fluid, of tho'se deleterious and septic 
matters which are occasionally formed on the internal surface of the 
uterus after delivery. *l. Certain conditions of the internal surface of 
the uterus following on parturition, such as mechanical injury to the 
uterus, inflammation of the internal surface of the uterus (particles 
of the placenta remaining and decaying in the womb, E. N.) 

Dr. Savage read a very interesting paper on the erectile and ve- 
nous system of the female pelvic organs before the Medical Society 
of London, in which he stated that he had discovered a new struc- 
ture hitherto not demonstrated, viz.: the bulb of the ovary. This 
body is inclosed in an unyielding fibrous envelope, an essential con- 
tradistinction as regards a mere venous plexus. The bulb of the 
ovary is a long, compact venous body, extending from the uterus to 
the ovary, which lies upon and is partially buried in it. Like the 
bulb of the vagina, it is provided with a special sheath, which estabr 
lishes its erectile character. The office assigned to this body is that 
of tending to push the organ itself towards the prehensile extremity 
of the fallopian tube. 



138 

In a discussion which followed upon this subject, Dr. S. allowed 
that this bulb of the ovary had been described before (namely by Dr. 
Kobelt ; see his work : [Die Weiblichen u. Mannlichen Wollustorgane, 
1843) ; but its character as an erectile organ had not been pointed 
out before he (Dr. S.) had mentioned it. 

After a full and scientific expose and a literary review of the facts 
concerning" the anatomical structure of erectile organs, Dr. Rouget 
comes to the conclusion, that there are three constituents necessary 
for tissues of an erectile character, viz.: arteries with a spiral course, 
vast venous reservoirs, and muscular trabecule. For the womb it 
is very easy to demonstrate the presence of these three elements, 
while it remains to analyze their mutual relation, and show that the 
number of vessels is larger than is required merely for the process 
of nutrition, and to prove that changes of volume, shape, and posi- 
tion are effected by the distension of these vessels 

The utero-ovarian artery, does not distribute its branches equally 
upon all portions of the womb. While near the neck of the womb 
its ramifications are few in number, and run in a pretty straight 
line, it divides abruptly near the fundus into a dozen or eighteen tor- 
tuous branches, so numerous and so much pressed against each 
other, that they cover entirely the lateral angles of the fundus uteri. 
Towards the inferior margin of the ovary the utero-ovarian vessel 
furnishes a series of a dozen branches, which start in rapid succes- 
sion from the upper border of the artery, and in ramifying close to 
their origin, directing their tortuous course towards the ovary, where 
they form also spires. The venous system of the womb is so much 
developed, that it looks, even uninjected, like a real sieve in many 
specimens. These masses of venous sinuses, when empty, give no 
idea of what they really represent, when fully developed by a com- 
plete injection. If this vascular system is separated from the inter- 
vening muscular stratum (by nitric acid) the erectile system of the 
body of the uterus, and below the ovary becomes distinct. This erec- 
tile body represents the exact form of the fundus and body of the uter- 
us, stopping short suddenly near the orificium internum (anatomic). 
Independently of the uterine sinuses, the erectile mass is formed of 
twisted and almost spiral venous canals, like those of the corpus 
spongiosum penis. Near the angles of the uterine body the arteries 
are so numerous that they form here the greatest portion of the vas- 
cular system. Immediately below the ovary there is a real corpus 
spongiosum, an erectile vascular tissue, containing spiral arteries, 
venous tissues, and muscular trabecula. The Corpus spongiosum 
(bulbus) of the ovary is elongated and flattened, exceeding some- 
what the long diameter of the ovary, while it is about l cm thick, 
and a little more than l cm high. 

These are the only erectile organs inside the female pelvis, the 
vessels of the tuba Fallopii not having the character of erectile or- 
gans. While injecting the vessels of the tube, no change of form or 
size, nor any movement whatever was observed, quite different from 
what was seen in really erectile organs. Nor have the walls of the 
vagina anything characteristic of erectile organs ; its arteries are 
even not spiral, while its venous system consists of a very thin vas- 



139 

cular network. Only the plexus of large veins running along its 
lateral borders, and a vascular ring near its orifice, form a kind of 
erectile body capable of being changed in form and size. 

The erectile character of these portions can be demonstrated by 
artificial erection, viz. : by immersing a fresh pelvis, with its con- 
tents, in warm water, and injecting the ovarian veins. As soon 
as the injected mass begins to fill the vessels, the erectile portion 
of the body of the womb is elevated in the cavity of the pelvis, 
performing a movement like that of the penis in erection. At the 
same time the uterus becomes more convex in front and behind, 
its borders round and smooth, while the cavity of the womb is en- 
larged. The ovary is somewhat elevated by the injection, while 
the tubes remain unchanged in their position. 

It remains to discuss the mechanism of this erection. In the womb 
this is easily demonstrated. The muscular borders of the uterus 
have the same rapport with the venous network, as the trabecule 
of the corpus cavernosum with its sinuses ; the same cause, muscu- 
lar contraction, must produce the same effect, viz.: the retention of 
the blood in the sinuses. But in the corpus spongiosum of the ovary 
it seemed to be impossible to bring it under the same law. An in- 
dependent muscular tissue was nowhere found. 

Dr. Rouget has found, by the study of comparative anatomy, that 
a muscular apparatus performs the expulsion of the egg from the 
ovary, and its progress towards the tube. The sexual organs of 
the lowest class of vertebrated animals (fishes) present two differ- 
ent types. In some of them the egg, when detached from the 
ovary, falls into the peritoneal cavity, which is lined by vibratile 
epithelium, and communicates externally by the way of particular* 
orifices. But the greatest number of osseous fishes have a geni- 
tal apparatus, similar to that of articulated animals. The eggs 
are developed upon the walls of a special cavity, or sac, having a di- 
rect external communication. Glands constructed on this principle 
are covered with a muscular layer. In the vertebrated animals and 
in the higher order of fishes, a special duct exists for transmitting 
out of the ovary the products developed in it, and this meatus is 
sometimes situated a considerable distance from the ovary. 

But the muscles covering these reservoirs and channels do not ex- 
actly fit their shape, just as the muscles of the intestinum crassum 
and of the seminal vesicles, do not follow the figure which their uneven 
shape requires. Another general law, pertinent to these organs, is 
that the terminal extremity of the organic muscles is always con- 
nected with some portion or other of the locomotive apparatus of the 
animal system, such as bones, muscular aponeuroses, tendons, or 
the body of muscles themselves. 

After a short analysis of the anatomical structure which forms the 
tubo-ovarian muscular apparatus of the fishes, reptiles, and birds, 
Dr. Rouget proceeds to describe that of the mammalia. As a sample 
is taken, the disposition of these organs among the ruminants, and 
that of the goat, is more particularly described. 

The body and the cornua of the uterus are situated in the middle, 
the tubes and ovaries in the lateral portions of a large membrane, 



140 

which, spreading in a transverse direction through the pelvic cavity, 
is attached by its ^two anterior extremities to the superior dorsal 
wall of the abdomen, by its two inferior and posterior extremities 
to the ventral wall. Throughout this membrane, even in its most 
transparent portions, the microscope reveals an extensive distribu- 
tion of muscular elements, a fact hitherto entirely overlooked by 
anatomists. 

The middle section of this membrane is really nothing but the ex- 
ternal layer of the muscular envelop of the uterus. In the median 
line of this membrane it is easy to distinguish a decussation of the 
muscular bundles from one side to another. The bundles which 
come from the lumbar region, the superior of which, condensed 
towards the free border of this membrane, are called ligamentum 
rotundum superius — descendent towards the cornua and the body of 
the uterus, and envelop the tube and the ovary in their course. 
Meeting at the median line, they cross each other with those of the 
other side, and in continuing their course, they are divided in three 
different sections ; the inferior ones run backwards towards the 
rectum and the anterior surface of the sacrum (ligam. recto-uterin). 
Those of the middle portion seem to connect themselves with a por- 
tion of bundles of the ligam. rotund, pubicum. The superior ones run 
towards the lateral portion of the basin and the symph. sacro-iliaca. 
It is the latter section which seems to receive a muscular bundle, 
which forms the superior border of the ligam. triangul. ovarii, and 
which, in passing above this organ, contributes to the formation of 
the muscular cord, which does there attach the ovarian fringe of the 
pavilion. 

• The ligamentum pubis rotundum is generally described as a mus- 
cular cord, which, coming from the spina pubis and from the labium 
majus, runs towards the cornu uterinum, or the superior corner of 
the womb. But this is, in reality, not the case. It is perfectly 
wrong to separate it from the neighboring portion of the ligamentum 
latum, with which it is in intimate connection. From the point 
where this ligament touches the anterior abdominal wall, it con- 
stantly sends forth muscular bundles, which spread fan-like over the 
entire anterior surface of the womb. After traversing the median 
line, those bundles, in an ascending direction, unite with the liga- 
mentum latum of the opposite side ; a certain portion of them forms 
the inferior board of the ligam. triangular, ovarii, and reach the ala 
vespertilionis of the tube. 

The superior bundles of the round ligament form, by their "entre- 
croisement," the muscular membrane which unites the uterine cornua, 
from whence they spread towards the ala of the tube. With this 
system are combined the greatest portion of the plicae semilunares 
Douglasii, and of the ligamenta utero-sacralia, which embrace the 
neck of the womb and crossing at the median line, combine with the 
opposite ligamentum latum. 

But, besides this "croisement" in the median line, there exists an 
antero-posterior entrecroisement in a line with the lateral borders of 
the womb and the cornua, while there is another muscular system, 
which remains only on one side throughout its course. This dis- 



141 

position is represented in different degrees of development in all 
classes of the mammiferous animals. 

All these muscular strata, as found among the different classes of 
animals, may be easily detected with some modifications in the 
woman. In order to establish the true anatomical character of the 
so-called peritoneal folds in the female, a portion taken from their 
outer layers must be kept for a few days in diluted (1 : 100) nitric 
acid, and afterwards, with the addition of four more drops of the 
acid, heated to commencing ebullition, by which process the inter- 
vening tissue is destroyed, while the muscular fibres may be easily 
recognized under the microscope. The best occasion to examine the 
disposition of the sexual organs in the human female is not the time 
of pregnancy, but that of foetal life and childhood. The uterus, with 
its appendages, taken from a young girl and examined with the 
loupe or under a small magnifying lens (from 20 to 200 diam.), 
after it has been wet with a solution of nitric acid (1) in water 
(100), offers the best means of recognizing, that at this time of life 
the human organs resemble, in many respects, those of the goat. The 
bundles coming from the round (pubic) ligament are fan-shaped, 
and spread over the entire length of the uterus, crossing in the 
median line those coming from the opposite side. Those bundles 
which are in connection with the ovarian ligament (mesoarium), are 
mostly derived from the posterior surface of the uterus. Descending 
from the superior and ascending from the inferior portion, they run 
in a convergent direction towards the ligamentum ovarii ; but being 
only more numerous at this point, they occupy the entire space of 
what is called, the serous, or rather the muscular membrane, on 
which the ovary is suspended. The bundles, interspersed with nu- 
merous oblong nuclei, which enter into the construction of the stroma 
ovarii itself, and inclosing the graafian follicles in their meshes, are 
very likely nothing but a continuation of those from the ovarian 
ligament (mesoarium), a fact well established in the ovary of the 
reptiles and birds. Besides, it is easy to find out, that a considerable 
portion of the bundles of this pretended ligament, proceed towards 
the inferior border of the ovary, entering, at its exterior extremity, 
into the composition of the muscular membrane, by which the pavil- 
ion of the tube is attached to the ovarian gland. The general fact 
of the ovary, the fallopian tube, and the uterus being enveloped in a 
common muscular membrane, is very important, more especially 
with regard to the connections established by these contractile fibres, 
between the ovary and its excretory duct. These connections result 
essentially from the double irradiation of the utero-ovarian and the 
ovario-lumbar ligaments in the membrane which connects the ovary 
with the trompe. It is easy to perceive that, by a contraction of 
these muscular bundles, the tube and its orifice are approached 
towards the ovary. The length of the peritoneal expansion (free bord- 
er of the mesometrium), spread out between the ovary and the tube, 
allows the pavilion to reach the remotest portions of the ovary. This 
disposition counterbalances the small extent of the opening of the 
tube, which scarcely covers one-third of the surface of the ovary. It 
is nothing but muscular activity, which forces the pavilion to adapt 



142 

itself just to that particular spot of the ovary, where the follicle is 
ready to break. The direction of the two orders of muscular bundles, 
attached at the lumbar region and at the uterus itself, comprises the 
full length of the tube and its peritoneal extremity, and sufficiently 
explains the mechanism of the movement of the tube towards the 
ovary. The whole question is reduced to that of the mechanism, by 
which a purse is closed by strings, going across its free border. 

These muscular expansions are not only destined to approach the 
tube to the ovary, but inclosing at once the large venous plexuses of 
the bulbus ovarii and those called plex. pampiniformis, they do com- 
plete the erectile character of these spongious tissues, thus rendering 
the similarity between the male and female organs more perfect. 
The erection of the spongious tissue of the uterus is immediately fol- 
lowed by uterine hemorrhage. It is a fact that the body of the 
uterus always has been found swollen, full of blood, more voluminous 
in women who died during menstruation. The erection itself results 
from a muscular spasm, which prevents the reflux of blood through 
the sinus efferentes. Therefore, ovulation, uterine erection, and 
menstruation have one and the same fundamental cause, viz., mus- 
cular contraction. The adaption of the tube to the ovary precedes 
the dehiscence of the vesicle, which lasts sometimes for- eight or ten 
days after the beginning of the rupture of the follicle. All this time 
the tube can only be retained close upon the ovary by a spasmodic 
contraction of the muscular layers which produce the adaptation of 
the tube to the ovary. But, at the saine-time, the' venous sinuses 
which are inclosed in this same muscular mesh-work, must neces- 
sarily undergo a partial compression, the result of which is tfie dis- 
tension and erection of the bulbus- ovarii. The accumulation of 
blood around and in the ovary must be of influence for the more 
rapid development and maturation of the ovulum. These modifica- 
tions in the circulation of the ovary do of course bring about a 
similar change in the uterus itself, the uterine and ovarian sinuses 
being in direct communication with each other. Both organs, there- 
fore, are placed in a state of erection by the same cause. If the 
erection of the ovary is not followed by a hemorrhage, this is owing 
to the tunica albuginea and the thick stroma of the ovary itself. 
But, in some abnormal instances, the ovarian erection may cause a 
hemorrhage, and this is certainly the most frequent origin of retro- 
uterine hematocele. The theory of the act of ovulation is exactly 
the same as that of the act of parturition, vomiting, and micturition, 
etc. As soon as the graafian vesicle has arrived to a certain degree 
of development, the distention Of the structures, which constitute 
the stroma, is the exciting point of a reflex action, which is propa- 
gated from the centres of the sympathetic nerve to the whole mus- 
cular apparatus of the internal genitals, to the mesoarium and to the 
mesometrium. But the ripening of an ovulum is not the only cause 
of the phenomena just described. No doubt sexual intercourse does 
very often produce a real, though transient erection of both uterus 
and ovaries, and may, therefore, if often repeated, call forth more 
frequent menstruation and ovulation. (In reading over Dr. Rouget's 
article, we were struck'as well with the novelty of the ideas present- 



143 

ed, as with the ingenuity of the experiments performed, and the vast 
amount of knowledge developed in these pages. We cannot speak 
too highly of this thesis, and. we desire to urge our readers to a 
perusal of the original article. — E. N.) 

Dr. Lee, in analyzing a number of cases of tubal gestation, stated 
that in all of them the egg was surrounded by a deciduous mem- 
brane, which closely adhered to the inner surface of the tube, while 
no decidua could be detected in the cavity of the womb. In most of 
the specimens exhibited, Dr. T. Clarke thought to find just the 
reverse, viz., a decidua in the uterus, and no deciduous formation in 
the tube. Still he admitted that in some cases a real decidua was 
formed in the tubes. Dr. Tyler Smith thought it but natural, that the 
mucous membrane of the tube was transformed into a deciduous 
membrane, while the lining membrane of the uterus was developed 
to such an extent as to resemble a decidua. Dr. Locock fully agreed 
with Dr. Smith's opinion. 



in.— PHYSIOLOGY AND PATHOLOGY OF PREG- 
NANCY, LABOR, AND PUERPERAL STATE. 

1. Mattei, on Diagnosis of Pregnancy. — Rev. the>. du Midi. 14. 

2. Hecker, on Diagnosis of Pregnancy. — Mon. — Schr. f. Geburtsk. xii. 6. 
Dez. 

3. Thompson, T. E., of Roseville, Arkansas, Practical Remarks on the 
Evidence of Pregnancy. — New Orleans Jour., xv. 4. . 

4. HelfFt, Influence of the different Seasons upon Conception. — Mon. — Bl. f. 
Med. Statistik. 5. May 15. 

5. Silbert, on Retardation of Pregnancy. — Compt. Rend. — Bull, de The*r. 
LV. 8. Oct. 30. 

6. Koch, C, Retention of a Dead Foetus in Uiero, 2 Months after the 
Normal Time of Pregnancy had expired. — Wiirtemb. Corr. — Bl. It. 

7. Hewitt, Gr., Menstruation during Pregnancy. — Lanzet I. 4. Oct. 

8. Oazeaux, on the Condition of the Cervix Uteri during the Latter Half 
of Pregnancy. — Mdm. de la Soc. de Chir. torn. iv. 

9. Miner, on a Case of the Birth of a Child without Pain. — Buffalo 
Jour. xiv. 4, Sept. 

10. Clay, Ch., Constitutional Diseases as a Frequent Cause of Abortion. — 
Midland Jour. Jan. 

11. Marcd, Influence of Pregnancy and Delivery upon Insanity. — Ann. 
Me"d. psych, iii. p. 359. — Amer. Med. Chir. Review II. 6. Nov. 

11. Taupel, H., De strepitum origine, qui audiunter in auscultando gra- 
vido uiero imprimis de strepitus placentaris origine. — Gryphiswaldae 
8 pp. 32. 

— Taupel, H., on the Origin of the Sounds Perceptible in the Pregnant 
Uterus, eye. (Thesis.) 



144 

12. Schmidt, G., Origin and Practical Value of the Navel- String Souffle. 
Scanzoni's Beitr. Z. Gcburtsk. B. 3, 1858.— New York Jour., V. 2., 
Sept. 

13. Lee, R. Clinical Midwifery. — Med. Tim. and Gaz. 433, 435, &c. 

14. McSherry, R., of Baltimore, Midwifery Gases. — Amer. Jour. 
LXII. Oct. 

15. Shedd, G., of Denmark, Iowa, Remarkable Cases in Midwifery. — 
Amer. Jour., LXXII., Oct. 

16. Houghton, R. E., Report of Cases in Obstetric Practice. — Penin- 
sular Jour., I., 6., Sept. 

It. Elliot, G. T., Jr., Difficult Cases of Labor.— New York Jour., IV., 
2. March, and V., 1, July. 

18. Irvine, J. P., Second Impregnation at the Fourth Month of Preg- 
nancy. — Med. Tim. and Gaz., 440, Dec. 4. 

1 9. Fracture of the Sternum During Labor. — Bull. Med., Fisiche. — Bull, 
dc Ther. LIV. June. 

20. Gibb, on a fall across a Chair by an Eight Month Pregnant Woman, 
with Laceration of the Genitals and Escape of Liquor Amnii ; Regener- 
ation of this Fluid and Delivery beyond full Time. — Lancet, May. 

21. Jones, T., Complete Evolution of a Child in JJtero. — Lancet, I., 6., 
Dec. 

22. Lautb, G., Presentation of a Leg ; Rotation of the Fcetus around its 
Long Diameter during Extraction ; Birth of a Living Child. — Gaz. 
de Strasb. 8. 

23. Heise, C, Tympanitis Uteri. — Monatschrift f. Geburtsk. Febr. 

24. Klaproth, Cases of Labor Complicated with Fibroid Tumors of the 
Womb.— Monatschrift f. Geburtsk. XI. Feb. 

25. Rlustratious of Difficult Parturition. — By John Hall Davis, M. D. 
London : Churchil 1858. 

26. Porter, T. G., of New London, Connecticut, " Meddlesome Mid- 
wifery is bad." — Amer. Jour. LXXII., Oct. 

21. Gardner, A. K., the Cervix Uteri in its Obstetric Relations. — Amer. 
Monthly, X. 3, Sept. 

28. Moone, W. P., of Lin wood, Tenn., on Obstetric Medicine. — Nash- 
ville Jour. April. 

29. Gray, T., Shortening the Duration of Labor. — Glasgow Journal, 
Jan. 

30. Du Rhumatisme de V Uterus, envisage specialement pendant la grossesse 
et V accouchement. — Par le Dr. V. Gautier. Geneve : Jules-Gme Fick. 
1858. 8vo. pp. 159. 

— The Rheumatism of the Uterus, Considered more especially during Preg- 
nancy and Parturition. By V. Gautier, M.D., &c. 

31. Braun, C, Pathogenesis of Hydrorrhea Gravidarum. — Wien. Ztschr. 
I. 11 New York Jour. V. 3. Nov. 

32. Massinat, R., on Hydrorrhea Gravidarum. — Gaz. de Paris 29, &c. 

33. Harvey, on Watery Discharge from the Uterus during Pregnancy. — 
Dublin Jour., Feb. 



145 

34. Brown, B., on a Singular Result of an Injury in the last Stage of 
Pregnancy. — Amer. Jotfr., April. 

35. Grail on the Action of the Diaphragma and the Abdominal Muscles du- 
ring Labor. — New Orleans Med. News, Feb. 

36. Betz, F., on Aflerpains and their Treatment.-r—M.emorsd). a. d. 
Praxis. III. 9. 

37. Critchett, on Sudden Failure of Sight during Lactation, Ophtalmo- 
scopic Examination. — Med. Tim. and Gaz., Jan. 30. 

38. White, on a Case of Effusion of Blood into the cerebellum in a Woman 
Six Months Pregnant. — Buffalo Jour. XIV. 4. Sept. 

39. Du traitement de la Syphilis chez les femmes enceintes. — Par Eug. 
Bertin. Nancy : Grimblot Vve. Rabois & Co., 8. pp. 15. Oompt. 
Rend, des trav. de la Soc. de Mdd. de Nancy. 

— The Treatment of Syphilis in Pregnant Women. — By Eug. Bertin, &c, 

40. Die vorzeitigen Athembewegungen. Ein Beitrag zur Lehre von den 
Einwirkungen des Geburtsaktes auf die Frucht. Von Dr. Hermann 
Schwartz, Privatdozent an der Universitat zu Kiel. Leipzig : 
Breitkopf und Hartel. gr. 8. pp. 308. 

— The early Respiratory movements. Being a Contribution to the Doctrine 
of the Influence of Labor upon the Foetus. By Herm. Schwartz, 
M.D., Lecturer at the University of Kiel, Leipsic, etc. 

41. Lehmann, L., on Rupture of the Uterus and the Vagina. — Monat- 
schrift f. Geburtsh., XII. 6. Dec. 

42. M'Clintock, a New Symptom of Rupture of the Uterus. — Dubl. 
Jour. — Edinb. Jour. Febr. 

43. Letennier, Case of Rupture of the Womb. — Gaz. de Paris, 22. 

44. Kelly, D., on Rupture of the Uterus. — Dubl. Hosp. Gaz. Jan. 15, 

45. Maes, Rupture of the Uterus; Recovery. — L'Union, XII. 121, 
Octob. 26. 

46. Bayne, Rupture of the Uterus; Gastrotomy; Death. — Gazette de 
Paris, 12. 

4t. De la mort subite dans Petal puerperal.-—? ar le Dr. A. E. Mordret, 
Mddicin au Mans, ex-Professeur d'accouchements, Directeur de la 
vaccine, Membre du Conseil d'hygiene de la Sarthe, etc. Mdmoire 
couronn^ par PAcaddmie dans la Seance du 15. Decembre 185*7. — 
Mem. de l'Acad. de MeU, Tom. XXII. 

— The Sudden Death of Women in Childbed. By A. E. Mordret, M.D., 
etc. Prize Essay of the Paris Academy of Medicine, etc. 

48. Marc d'Espine on the Frequency of Death among Pregnant and De- 
livered Women and the Influence of General Causes upon this Accident. 

— Gaz. de Paris, 19. 

49. Eimer, Sudden Death after Delivery from Entrance of air into the 
Blood.— Aerztl. Mitth. S. Baden. XII. 1. 

50. Beullac, Sudden Death Immediately after Confinement. — Bull, de la 
Soc. Mdd. de Marseille. 

51. Cavenne, Sudden Death at the Beginning of Labor. — Abeille Med. 
Febr. 

10 



146 

52. — Des morts subites chez les femmes enceintes on recemment accouche" es. 

Par le Dr. Eug. Moynier. Mdmoire auquel l'Academie, Imper. de 

Mdd., a accorde une mention honorable, etc. Paris, Victor Masson. 

In 8. pp. 168. 
— Sudden Deaths of Pregnant and Recently Delivered Women. By E. 

Moynier, M.D. PrizeEssay, etc. 

53. Sauvel, L., Appearent Death of Two Women, delivered under very 
Different Circumstances; Recovery of Mothers and Children. — Rev. 
Thdr. du Midi. XII. June. 

54. Lcescher, on Delivery after Death. — Vierteljahrschr. f. ger. Med. 
XIV. July. 

55. Frentrop, on a Case of Delivery after the Death of the Mother. — Ibid. 
XIV. Octob. 

56. Fessenden, B. T., of Plymouth, N. C, a Case of Puerperal convul- 
sions with Spontaneous Expulsion of the Fcetus after Death. — North. 
Carol. Jour., I. August. 

51. Thornton, G. W., Extraction of a Living Child by Turning after 
Death of the Mother. — Cincinnati Lancet and Observer. Febr. — 
Amer. Jour., April. — New York Jour. V. 3. Novemb. 

58. Rigby, E., on the Natural Position of Women during Labor. — 
Schmidt's Jahrb. 

59. Klopsch, Microscopical and Chemical Examination of a Lithopoedion. — 
Reichard's Studien des physiol. Instit. zu Breslau. Leipzig, 1858. 

60. Hall, T. W., on Stomatitis Materna. Cincinnati Lancet and Ob- 
server, April. — New York Jour. V. 3. Novemb. 

The work to which we would direct the attention of our readers 
more particularly among the numerous contributions to obsteteric 
pathology, is that of Dr. Schwartz on the influence of labor upon res- 
piratory movements of the foetus in utero, which is equally impor- 
tant from a scientific as from a practical point of view. From 
France we have received Dr. Mordret's elaborate treatise on sudden 
death of puerperal women, to which a prize has been accorded by 
the French Academy of Medicine. This article touches upon the im- 
portant question of entrance or development of air in the blood, an 
accident which occurred, as we have reason to believe, in Dr. Elliot's 
interesting case, mentioned below. The most important contribu- 
tion from England is Dr. Davis's " illustration of difficult parturition," 
a faithful guide in the time of need for the practitioner and the stu- 
dent. 

Dr. Hecker subjected 2593 pregnant women to an examination, in 
order to test the correctness of the generally current opinion, that the 
permeability of the internal mouth of the uterus, was a sure sign of ap- 
proaching labor. But of this number 946 presented an internal orifice 
sufficiently open for the passage of the forefinger ; 123 were mucipa- 
rous, and 223 primiparous women. In every instance the time of ex- 
amination and that of beginning labor were noted. By a compari- 
son of these, the value of the rule, as named above, was not materially 
changed, with this restriction, that only in 60 out of 100 primiparous 



147 

women the open condition of the os can be taken as a sign of labor 
in the next few days, and that only in 70 out of 100 multiparous wo- 
men with open os, delivery was not delayed longer than fourteen 
days after this condition was ascertained. These results show how 
careful we have to be in our prognosis with regard to beginning la- 
bor : especially if we consider the fact that 6 out of 100 primiparous 
women presented on examination an open internal orifice, although 
they were only 9 (lunar) months pregnant, while the same was ob- 
served in ten per cent, of the multiparous women. 

After the researches of Dr. Silbert, children born after protracted 
gestation are unduly developed, and he therefore proposes induction 
of labor at the end of the full term, whenever gestation is suspected 
to be protracted. 

Dr. Hewitt reports the case of a lady who menstruated regularly 
every fourth week, and did not miss her courses in three successive 
pregnancies. The discharge continued to appear every fortnight, 
though of a paler color. 

Dr. Cazeaux thinks that ulcerations of the cervix are very fre- 
quently found in multiparous women, during the latter part of preg- 
nancy. He has observed them in seven-eighths of the cases, confin- 
ing this statement to the last third of pregnancy. This, therefore, 
seems to be the normal condition, and should be considered as a con- 
sequence of the progress of gestation, owing to the excessive con- 
gestion proper to the pregnant state. Consequently all treatment 
with regard to them is unnecessary. Corresponding with this view, 
is the fact that five *or six weeks after delivery, no traces remain of 
these ulcerations. 

In regard to the statements of Boys de Laury, Bennet, and others, 
as to the frequency with which abortion and various puerperal causes 
are produced by ulcerations, it is of importance to distinguish be- 
tween ulcerations that have preceded pregnancy, and those which 
have only become developed after the formation of the germ. Cazeaux 
doubts the justice of Bennet's statement, that these ulcers are a fre- 
quent cause of obstinate vomiting in pregnancy. He has had the 
opportunity of examining four primiparse, reduced by vomiting to 
the last stage of marasmus, in whom the cervix remained perfectly 
healthy. 

Dr. Clay reports three cases of women who after having miscar- 
ried several times, underwent a mercurial treatment before the next 
pregnancy, in consequence of which all three gave birth to full grown 
living children. In the third case mercury was first given during 
pregnancy, but the woman miscarried as usual ; after this, she, as well 
as her husband, began to take mercury before she conceived again, 
and she carried her child to the full term. 

Dr. Marce thus concludes an interesting paper illustrated by cases. 
1. We cannot protest too strongly against the practice of those phy- 
sicians who advise or allow pregnancy in insane women, for it re- 
sults from the facts mentioned in this paper that, in the great ma- 
jority of cases, pregnancy and delivery, so far from exerting a favora- 
ble influence on insanity, seem on the contrary, to hasten the 
progress of the disease towards dementia. If in certain exceptionable 



148 

cases (2 in 16) pregnancy has suspended the progress of the disease, 
the improvement has been only temporary, and the insanity has re- 
appeared after delivery. 2. In some few cases (4 in 16) remarkable 
especially for the predominance of erotic symptoms, pregnancy has 
exerted a beneficial influence on the cure. 3. When insanity becomes 
developed during pregnancy, it very often remains incurable, even 
after delivery, or is cured so long after, that no influence can be at- 
tributed to the latter in the termination of the nervous affection. 4. 
Sometimes, however (3 in 10 cases), the disease disappears after 
delivery, and these cases must be regarded as sympathetic. 5. De- 
livery in the insane is often remarkable for the slight amount, or 
even complete absence of pain. 

The opinions of the different authors, who have paid attention to 
the navel-string souffle being divided, as to its true seat and nature, 
Dr. Schmidt feels justified in the publication of five instances of this 
phenomenon, perceived before the child was born, out of 500 obste- 
trical cases, all of which were thoroughly examined with the stetho- 
scope. 

Case 1. — The child was born in a state of asphyxia, and could 
not be revived. The autopsy was performed by Prof. Virchow, 
who found a decided hypertrophy of the right ventricle of the heart, 
insufficiency of the valvula mitral is et tricuspidalis, and a deposition 
of several red, gelatinous corpuscula on both valves. 

Case 2. — When the head of the child was born, the navel-string 
was found twisted around the neck twice, and so strong, that the 
vessels of the neck were compressed, in 'consequence of which, the 
face had a cyanotic color. The child died after a few short inspira- 
tions. 

Case 3. — The sounds of the foetal heart were heard clear and dis- 
tinctly, immediately before the rupture of the amnion. When the 
water had been discharged, a prolapsus of the umbilical cord was 
discovered, upon which the head of the child was pressing with con- 
siderable force. Auscultation applied at this moment, discovered not 
the former sound of the foetal heart, but instead, a souffle, which dis- 
appeared as soon as the prolapsed string was removed into the cavity 
of the womb. 

Case 4. — The sounds of the foetal heart were accompanied by a 
strong souffle. Still, when the child was born, the navel-string was 
not twisted round the neck ; the child was healthy, and the sounds 
of his heart found in good order. 

Case 5. — Instead of the first sound of the heart a souffle was de- 
tected by auscultation. When the head was born, the umbilical cord 
was found tightened around the neck. The child was asphyxiated, 
and it was half an hour before it could be declared out of danger. 

From an analysis of these cases, Dr. Schmidt comes to the conclu- 
sion, that the so-called umbilical souffle may take its origin : a. From 
diseases of the foetal heart, b. From circumvolution of the umbilical 
cord around the neck of the child, c. From other compressions of 
the navel-string depending upon the position of the child. 

In regard to the practical value of the funic-souffle, Dr. Schmidt is 
of opinion, that its presence, in most cases, indicates danger to the 
life of the child. 



149 

« 

Dr. McSherry reports a case of delivery, at the full term, of a pu- 
trid child, in a case of cancer of the womb ; the patient died soon 
afterwards. The author proposes the Caesarian operation in far-gone 
cancer of the pregnant womb, in order to shorten the sufferings of 
the mother and save the life of the child. 

Dr. Shedd reports a case of labor without pain, and one interest- 
ing case of hydrorrhea a uteri with enormous discharges of water 
during pregnancy. 

Dr. Houghton reports a case of shoulder presentation, which ter- 
minated by spontaneous evolution. The vehemence of uterine con- 
traction prevented the intended operation of turning, and could not 
be checked by chloroform. The author wonders why chloroform did 
not subdue uterine contraction. — It is a well-known fact, that uterine 
activity, as well as that of all organic muscles, is very little influ- 
enced by anaesthetic agents. — E. N. 

Dr. Elliot gives an account of several cases of difficult labor, some 
of which are apt to excite the liveliest interest of the profession ; 
above all, the case of Mrs. E., is an unicum in its way, thus justify- 
ing a somewhat lengthy analysis. Mrs. E. exhibited already during 
gestation unmistakable signs of existing morbus Brightii, so that Dr. 
Elliot put her under a rational treatment, in order to avoid, if pos- 
sible, the occurrence of puerperal convulsions during delivery. 
When the first pains set in, it soon became manifest, that the os uteri 
was so unyielding, that the warm douche was thought necessary to 
overcome this obstacle. But the os remained as undilatable as it 
had been for twenty hours. Therefore the cervix was divided with 
Simpson's uterotome, and the long forceps applied, by which Dr. 
Elliot succeeded to deliver a living female child. After all was 
over, the mother seemed to be doing very well, when suddenly an 
alarming change came on in her expression, pulse, temperature, and 
respiration. The last was slow, jerking, and abdominal ; the pulse 
exceedingly feeble and slow ; the face and extremities very cool ; the 
uterus remained well contracted, no haemorrhage occurred. This 
alarming condition was successfully removed by the use of stimu- 
lants, and she had some refreshing naps, when suddenly a similar 
change tQ that of the previous night came over her. She became ex- 
tremely restless, throwing herself completely on her right side, rais- 
ing herself on her heels and shoulders, and died immediately after- 
wards. The body was kept in a room without fire, and the windows 
open, the temperature being near the freezing point. 

Post mortem examination 27 hours after death. — The face was greatly 
swollen by emphysema and the surface of the body down to mid-leg, 
and to the wrists, crepitated in the most marked manner ; post mor- 
tem lividity over the back, and greenness of decomposition, with 
bullae over the lateral aspects of trunk. On opening the abdomen, 
there was an unusually great escape of gases ; interior of the body 
yet warm. Both plewrce universally adherent, nothing of interest in 
the lungs. Heart of normal size, apparently fatty with patches of 
atheroma along the aorta ; no clot in pulmonary artery. Peri- 
cardium normal. Blood coagulated. Abdomen: No peritonitis, 
subperitoneal cellular tissue everywhere emphysematous. On 



150 

greater curvature of the stomach, cellular tissue around gastro- 
epiploic vessels, so aerated as to simulate distension of vessels. 
The intestines crepitated everywhere from emphysema of their sub- 
peritoneal cellular tissue. Liver crepitated everywhere to the touch, 
and was so friable, as readily to break down in the necessary manip- 
ulations for removal. Spleen, with similar crepitation. Kidneys 
excessively soft, crepitating to the touch ; their capsules dissected 
by the emphysema. Uterus firmly contracted and emphysematous ; 
displayed two subperitoneal fibrous outgrowths, which were diag- 
nosticated during life ; no appearances of sphacelus nor of lacera- 
tion extending to the peritoneal coat were observable ; cavity 
contained a small clot of blood. Microscopical examination con- 
ducted by Drs. Clark and Isaacs. The numerous whitish spots on 
surface, and in muscular tissue of the heart, consisted of granular 
matter, with globules of oil. Liver fatty. Kidneys far advanced in 
Bright's (fatty) degeneration. Dr. Elliot in the adjoined remarks, 
ascribes the sudden death, in this instance, to an effect of the exist- 
ing disease of the kidneys. Lastly, Dr. Elliot remarks, that the 
entire literature, as far as it was in his reach, did not contain a 
case of post-mortem decomposition of the same extent, or equal 
rapidity. Added, are a number of interesting obstetrical cases, 
under the following heads : Case. — Woman deserted by her phy- 
sician ; child dead ; uterus distended with gases ; version ; death. 

Case. — Tedious labor ; Forceps ; Safety to mother and child ; 
Novel views of uterine haemorrhage. 

Case. — Neglected transverse presentation ; version ; death. 

Case. — Deformed pelvis ; Forceps ; Death from perforation of 
uterus by sacral promontory ; child died two days after from apo- 
plexy. 

Case. — Forceps ; Puerperal fever ; Bronchitis ; Death from uterine 
haemorrhage, eleven and one-half days after delivery ; child did well. 

Case. — Hysterical convulsions and hemiplegia. 

Case. — Puerperal mania. 

Case. — Forceps ; Puerperal fever ; Death ; No autopsy. 

Four Cases of ; Puerperal fever ; Recovery ; (Morphium and Tr. 
Ver. viridis treatment). 

Case. — Puerperal fever ; Death and Autopsy. 

Case. — Puerperal convulsions ; Recovery. 

Case. — Rigid os ; Douche ; Forceps to head transversely placed in 
pelvic excavation ; Mother recovered ; child dead before delivery. 

Case. — Rigid os and lingering first stage ; Douche ; Forceps ; 
Mother recovered ; Child died on third day from other causes. 

Case. — Arrest of head by promontory of sacrum ; Forceps ; both 
olid well. 

Case. — Forceps in superior strait ; both did well. 

This is quite a number of interesting cases, illustrating better the 
rules to be followed in practical midwifery, than volumes of theoret- 
ical treatises. Dr. Elliot, in advocating the douche for the manage- 
ment of a rigid os, strongly recommends never to neglect manual 
dilatation afterwards. Many of the cases in which the douche is sup- 
posed to have failed, come within this category, the os preserving 



151 

• 

the same dimensions, and the same deceptive feel of rigidity which 
originally motived the douche, but now yielding to the dilatation of 
the fingers, as brown paper would do when wetted. 

Dr. Irvine's case of superfcetation is of no value whatever. The 
first foetus born was of a four months growth, which is certainly 
nothing but a twin-child, which died when four months old, and was 
compressed by the growing second child, without being decomposed. 
Nothing is mentioned about the formation of the uterus. 

Mrs. J. B. was taken in labor and attended by Dr. Jones, at the ex- 
piration of her third pregnancy ; after fifteen hours of pain, she was 
delivered of a male child, and about ten minutes afterwards, the 
membranes of a second foetus began to come down. On this being 
ruptured, both feet ascended low in the vagina, when Dr. Jones 
grasped both legs high above the ankles, and waited for the return 
of an expulsive pain, which soon coming on, Dr. Jones began to 
make some traction. But the legs were forcibly drawn from his 
grasp, until they quite passed above the pelvic brim, and their place 
then became occupied by the head, which soon descended (face to 
the sacrum) and the labor was rapidly completed. 

Dr. Heise attended a lady in her confinement, during which, after 
the discharge of the water, the uterus became suddenly enormously 
extended and very painful, while the patient became excited and 
feverish. Though the pains were pretty strong, the labor did not 
advance any, and Dr. H. recognized a constriction of the in- 
ternal uterine orifice round the neck of the foetus, which seemed to 
yield after external application of extract of belladonna, for the head 
of the child now advanced and was finally born, during and after 
which a great quantity of a stinking gas was discharged with a gur- 
gling noise from the uterus, while all the distressing symptoms left 
the patient immediately. The child was macerated, and the doctor 
explains the sudden and unusual dilatation of the uturus from the de- 
velopment of gases, originating from the contact of the dead foetus 
with the atmospheric air, after the rupture of the membranes, while 
their escape was prevented by the ensuing constriction of the orifice 
of the uterus around the foetus. 

Dr. Hall Davis's book deserves the greatest attention of the pro- 
fession, being the result of a more than twenty years' observation in 
private and hospital practice. The book is divided into two parts, 
the first dogmatical ; the second illustrative. The former opens 
with a short introduction, pointing out the causes of obstructed la- 
bor, and generally indicating the principles upon which such diffi- 
culties are to be overcome. The second chapter contains strictly 
practical matter, treating mostly of difficult forceps deliveries. 
The author does not approve of Dr. Simpson's proposition of turn- 
ing instead of using the long forceps in cases of contracted pelvis. 
Next follows the subject of premature labor and of craniotomy. He 
ascribes the fatality and evil results of the latter to neglect of not 
sufficiently reducing the bulk of the head and other hard parts. Face 
and breech presentations are next treated in their particular bear- 
ings. With regard to the use of chloroform, he thinks that it pro- 
duces, in most cases, the necessary relaxation, while at times it failed 



152 

in effecting that object, although the patient was reduced to perfect 
unconsciousness. In some instances it appeared to have predisposed 
to hemorrhage after delivery, the uterus being left in a state of iner- 
tia. The second portion of this book contains, besides, a great num- 
ber of very interesting and valuable cases. From the statistics given 
in the appendix it appears that the mortality among 1302 mothers, 
who came under Dr. Davis's notice as patients of the charities, to 
which he is attached, only amounted to sixteen. The book altogether 
is a real English one, having throughout a practical tendency, and 
being written in a style plain and to the point. 

Dr. Porter read a very elaborate and scientific article on meddle- 
some midwifery, before the New London County Medical Association. 
He advises the cautious use of the tampon in abortion, not, of course, 
its disuse. He speaks of unnecessary venesection in pregnancy, not 
denying that it may be properly resorted to in many eases. He fur- 
ther dissuades from unnecessarily converting one presentation into 
another, if not imperiously demanded. The same is true in regard- 
to rupturing|the membranes, to management of nates presentations, 
and to the dilatation of the os uteri. 

Dr. Gardner, when speaking of rigidity of the os and its treat- 
ment, strongly advocates mechanical dilatation by sponge tents, in- 
cision and the blades of the forceps in cases of need, where internal 
remedies have failed to overcome its resistance. 

Dr. Moore's paper, read before the Tennessee State Medical Socie- 
ty, is an account of six complicated obstetrical cases, which were 
successfully treated by internal medicines, or by turning. The arti- 
cle is written against the spreading use of the forceps and the perfo- 
rator, in this country. 

Dr. Gray recommends to irritate the nipples as soon as labor 
pains come on, and continue the stimulation as long as it lasts, in 
order to increase the action of the uterus. — The same has been pro- 
posed and executed by Scanzoni. — E. N. 

Dr. Gautier's volume on uterine rheumatism is intended to repre- 
sent a complete description of the rheumatic affections of the womb ; 
therefore, the author comprises in his description the disease gener- 
ally denominated neuralgia uteri, which he believes to be of a rheu- 
matic nature. The book contains a considerable number of clinical 
observations upon which the following conclusions are based : 1. 
The disease described as irritable uterus, uterine neuralgia, etc., is 
of the same nature, and offers the same symptoms, as that, called by 
some authors, rheumatism of the uterus in its empty state. 2. This 
same disease is observed at the time of pregnancy, from the second 
month up to the end of the ninth. 3. This affection has been gener- 
ally described as uterine rheumatism, when it was observed during 
pregnancy ; but its nature does not differ at all, from that of hyster- 
algia in the non-pregnant uterus ; it, therefore, would be just to 
unite both affections under one designation. 4. Inasmuch as this 
disease represents all the characters of a muscular rheumatism, the 
name of rheumatism of the uterus ought to be retained. 5. Those af- 
fections described as erethism, hypersesthesy, convulsibility, trismus, 
tetanus, cramps, spasmodic contractions, etc., of the womb, are all 



153 

nothing but varieties of uterine rheumatism in their primitive form. 
6. Rheumatism of the uterus does appear with the same symp- 
toms, in the non-pregnant state of the womb, during pregnancy, dur- 
ing labor, during and after delivery, t. Rheumatism of the uter- 
us is not a simple inflammation of the uterus, nor an endometritis. 
Both differ from each other in the respective symptoms, course, and 
duration. 8. Rheumatism of the uterus during pregnancy and 
parturition, is not dangerous for the mother ; if death follows, this is 
owing to a complication. 9. Rheumatism of the uterus is at 
times a cause of danger or even death for the child. 10. The prin- 
cipal remedies for uterine rheumatism during pregnancy, are opium 
and tepid baths. 11. Inhalation of chloroform is the principal remedy 
for rheumatism during labor. 12. From the identity which exists 
between hysteralgia and uterine rheumatism, it is reasonable to as- 
sume the identity of muscular rheumatism and neuralgias in general. 
Dr. Braun says : Hydrorrhea is a periodical discharge of a yellow- 
ish, sero-albuminous fluid from the genitals of pregnant women, 
which is unconnected with the rupture of the membranes, or the dis- 
charge of the amniotic liquor. Hydrorrhea seldom occurs before 
the third month, but generally at a more advanced stage. It may 
appear only once, or more often, sometimes imitating the menstrual 
types, ceases generally after delivery, or continues in a few instances 
for a length of time during the puerperal state. In consequence of 
the red color of the fluid, the hydrorrhea has been often mistaken 
for a menstrual discharge of blood. Dr. Braun believes that 
the hydrorrhoeal fluid is a secretion or rather albuminous exu- 
dation of the inner surface of the womb, which appears in 
an intermittent typus, elevating a portion of the chorion from 
the decidua, or the latter itself, thus forming a reservoir for the 
fluid, from which it escapes occasionally through the mouth of the 
uterus. Similar albuminous discharges have been observed in the 
non-pregnant state, especially when fibrous 'tuinors were in the cavity 
of the womb. Another proof that Dr. Braun's views are perfectly 
right, is the fact that after delivery the foetal membranes are found 
intact, and that the quantity of liquor amnii is not lessened in cases 
of hydrorrhea. The microscopical examination of a placenta ex- 
pelled after hydrorrhea, detected a recently formed membrane of 
cellular tissue on its convex surface. 

In a paper — read at a meeting of the Cork Medical and Surgical 
Society — Dr. Harvey reports a case of hydrorrhea uteri gravidi, and 
gives it as his opinion, that the water discharged in • similar cases, 
comes from the amniotic cavity, owing to occasional solutions of con- 
tinuity, admitting of discharges from time to time, which either close 
again, or admit refilling to a certain extent, by a fresh secretion of 
its peculiar fluid. — It would be too lengthy to prove on this occasion, 
that Dr. Harvey is entirely mistaken with regard to the explanatiom 
presented. Suffice it to say, that our experience in this matter leads 
us to agree with the views taken by Mr. Braun. — E. N. 

Dr. Brown reports a case of a very large thrombus of the vagina, 
formed after a severe fall on the back, one day before delivery, which 
suddenly increased after confinement, to an enormous size. The case 



154 

resulted successfully by hourly application of gallic acid, in simple 
doses, combined with the use of strong anodynes. 

Dr. Betz remarks, that the cause of afterpains is not always to be 
found in a pathological condition of the womb itself. At times the 
situation of the womb after delivery is such, that it presses against 
a part of the bones which form the entrance of the pelvis ; in this 
instance the patient must be brought into a position which enables 
the womb, to move away from its former place to a more harmless 
location. Added is the history of a case, where afterpains originated 
from the fact, that the uterus by its peculiar position exerted a press- 
ure upon the left horizontal pubic bone ; the womb was removed from 
the os pubis, whereupon the afterpains disappeared. 

Dr. Critchet examined the eye of a patient, who had suddenly lost 
sight of the right eye, and found that a filmy, colored membrane of 
considerable size floated in the lower half of the eye, at a little dis- 
tance from the retinal surface. Only one-half of the entrance of the 
optic nerve could be seen, the other being covered from view by a 
crescentic patch of what was probably extravasated blood. 

Dr. Schwartz's work on early respiratory movements of the foetus, 
is one of the most elaborate and scientific researches we have met 
with for years. The much contested question of foetal respiration in 
utero is discussed in a more thorough manner, than it has been done 
up to the present time, developing quite oew and well supported 
views on the vital connections between mother and child. The dis- 
cussion opens with a full historical sketch of the treatises published, 
regarding the different points in question, and in a few preliminary 
remarks the subject to be inquired into, is laid open to the reader. 
The author's intention is to show the intimate connection between a 
disturbed foeto-placentar circulation during the physiological or 
pathological progress of labor, and respiratory movements of the 
foetus, with all its bearings upon theory and practice of every day's 
and of legal midwifery. If this connection should be proven to be a 
law, then the very act of parturition bears in itself the danger of 
suffocating the foetus, and death of the child during delivery must be 
considered as death by suffocation. These considerations constitute 
the turning point of Dr. Schwartz's thesis, the elements of which are 
treated in the following manner : He first proceeds to reconsider 
the doctrine of placentar respiration, which he endeavors to 
strengthen by conclusions, based upon the physiological manifestation 
of intra-uterine life. After this he intends to show, by direct obser- 
vations, that the next consequence of interrupted foeto-placentar 
respiration was the beginning of respiratory movements of the 
foetus. Next is considered the influence of the act of parturition 
upon the early respiratory movements of the foetal thorax, and fur- 
ther on the post mortem appearance of children, who died during or 
shortly after birth, compared with the respective process of delivery, 
by which their death was caused. 

The question of foetal respiration in utero is far from being decided 
in one or the other way. The opponents considered a foetus in utero 
as part of the mother, attributing to it only an indirect respiration, 
such as every single member of the body has its capillary respira- 



155 

tion, inasmuch as it receives an oxygenized blood, for which carbon- 
nized blood, with the ashes of nutrition, is exchanged. But Dr. 
Schwartz holds that the foetus lives a life for itself, with its own 
sanguification, its own peculiar nutrition, and its own respiration, 
i. e., the foetal blood discharges in the placentar capillaries carbonic 
acid, and there receives oxygen, which it discharges in the capilla- 
ries of its body for the former gas. For proving this the author 
follows a double way, first showing the effects of respiration for the 
foetus, and secondly, the influence of a suspension of this presump- 
tive mode of respiration. After the researches of competent men, 
the blood in both the umbilical vein and arteries exhibits 
no difference in color, not because the want of oxygen for 
foetal life is so trifling, that its minute quantity is insufficient 
to brighten the coloration of the blood, but because we are un- 
able to get at the blood contained in the umbilical vessels, without 
disturbing previously the uterine and placentar circulation, by the 
manipulations necessary for this experiment. This same circum- 
stance explains the impossibility of finding different gases in the 
different umbilical vessels. Therefore, another way must be followed, 
to prove the reception of oxygen by the foetus. Oxygen is an indis- 
pensable requisite for the formation of uric acid, and especially so 
for urea, two elements often demonstrated in the urine and kid- 
neys of the foetus by several distinguished authors (Denis, Wohler, 
Prout, Virchow, Martin, Hoogeweg). Dr. Schwartz adds two more 
observations of his. The generation of an increased temperature in 
the living organism is due to the oxydation of matters, and it seems 
an established fact, that the foetus for himself, is apt to produce 
warmth, independently of that which is conveyed to it with the blood 
of the mother. Another proof for the presence of oxygen in the foetal 
blood is the excitability of the foetal nerves and muscles, which 
function is inconsistent with the absence of free oxygen. In the 
chapter on the immediate consequences of interrupted placentar cir- 
culation, the author describes a number of experimental vivisections, 
by which it was demonstrated, that the beginning of inspiratory 
efforts was a constant, next, and immediate result of an injured cir- 
culation of the blood in the placenta. But, if this is really- the case, 
the question arises, why the foetus does not make respiratory move- 
ments during every labor, in consequence of the disturbed foeto-pla- 
centar circulation, as connected with every strong labor pain. 
In order to dissolve this problem the following points are ventilated : 
1. From what depends the first inspiration of the foetus ? Is the 
inspiration observed, really the first one ? and if this be the case, 
how can it be explained ? 2. Under which circumstances does the 
act of parturition effect a deficiency of oxygen, and an increased 
amount of carbonic acid in the foetal blood, and in consequence, the 
beginning of respiratory movements and symptoms of suffocation, or 
rather intoxication ? How can this be recognized ? What are their 
evil influences upon the foetal and extra-uterine life ? 3. To what 
degree does the act of parturition produce anomalies in the distribu- 
tion of the blood in the foetus ? What influence do they exert upon 
the condition of the foetus or the new-born child ? 



156 

The answer upon these questions was derived from a number of 
1,300 deliveries. Out of the children born 14 died before beginning 
labor ; 78 died during and in consequence of labor ; 112 were born 
still and resuscitated ; 60 were taken sick and died during the first 
fortnight after delivery. By a very simple experiment (opening the 
vein of the cord) it can be demonstrated that the fceto-placentar cir- 
culation is cut off, as soon as the child is born. The first inspiration 
is observed at the moment, when the body of the child begins to pass 
through the os exterum, or earlier (before the shoulders are born), 
when the intra-uterine circulation has been interrupted by a strong 
pressure from the expulsive pain, by a circumvolution of the cord, by 
an early detachment of the placenta, and so on. From this it appears, 
that the thirst for oxygen is the chief factor for the inspiratory 
activity of the new-born child, and the observations of Osiander, 
Martin, Hohl, and others, give sufficient evidence, that the access of 
air to the new-born child, is not necessary for the beginning of respi- 
ration. On the other hand, it happens very often, that respiratory 
movements of the foetus in utero can be perceived by the hand, 
introduced for the purpose of turning, whenever the cord is tem- 
porarily compressed by the operating hand. Several observations 
are reported. The fact that the change produced in the utero-foetal 
circulation, by every pain, does not excite respiratory movements in 
the child, may be explained in the following manner : During a pain 
the blood in the uterine sinuses is not only driven back into the 
maternal system, but part of it into the placenta, from which it is 
promoted with greater force into the umbilical vein, while this same 
compression of the placentar vessels prevents the foetal blood from 
escaping with the same force, as it did before the pain, through the 
umbilical arteries ; thus, during a pain, a comparatively larger quan- 
tity of oxygenated blood is conveyed to the foetal heart, and allowed 
to stay there for a greater length of time. This circumstance also 
accounts for the diminished frequency of foetal pulsations, as long as 
the pain is lasting. 

From a Dumber of fifty-nine observations, reported minutely, it 
appears that the anatomical alterations of children, who died in con- 
sequence of the act of parturition, are twofold. One series com- 
prises the consequences and symptoms of a disturbed exchange of 
gases in the foetal blood, and may be called asphyxia, while the other 
shows the effects of a mechanical hindrance in the circulation. 
Although in most cases, both of them are combined, each of them 
has a distinct influence upon the foetal life. Asphyxia of the foetus 
is an intoxication of the foetal blood, by a chemical alteration of its 
ingredients, and is caused by an insufficient receipt of oxygen through 
the maternal blood. Circumstances which are apt to interrupt the 
normal distribution of gases in the foetal blood, are : death, or severe 
sickness of the mother, early detachment of the placenta, compres- 
sion of the cord. But the most frequent and most insidious obstacle 
for the foetal respiration, is a lasting and strong muscular action of 
the parturient uterus, inasmuch as it diminishes the amount of oxy- 
genized blood in the placenta, by compression of the uterine vessels. 
That such is the case, is clearly proven, by several of the above- 



157 

named observations, and by the statistics of Dr. Veit, from which it 
appears, that the danger for the foetal life increases in proportion 
with the number of hours consumed for labor, and especially for the 
last stage of labor. 

The symptoms of foetal asphyxia are an altered composition of the 
foetal blood, and the beginning of inspiratory movements. The 
alteration of the blood can be easily recognised in still-born children, 
the blood taken from both umbilical arteries and veins, is unusually 
dark and thin, while the extravasations of blood, deposited during 
intra-uterine life in still-born children, are void of fibrinous matter, 
which appearances are also found in adults, who died from asphyxia. 
The early respiratory movements of the /eetus, in some rarer in- 
stances, could be perceived by some authors in the form of the so- 
called vagitus uterus, while in a considerably large number of cases, 
these movements could be felt by the hand introduced into the womb 
for the purpose of turning, or for reposition of a prolapsed funis 
(Observ. 8, 5, 15, 16, 19, 54, b*l). A reliable symptom of respiration 
in utero is the rattling noise, always perceived with the first inspira- 
tions of resuscitated still-born children. The intensity of these garg- 
ling sounds depends, from the quantity of liquor amnii aspirated in 
utero, and consequently from the frequency and energy of the early 
respirations. Accordingly, with these phenomena, the nose, choanes, 
pharynx, larynx, and even the trachea and smallest bronchia, are 
found replete with a viscid mucous from the cervix, with liquor 
amnii, blood, meconium, or vernix caseosa, in almost every child which 
died during labor. In very rare instances air is found in one or 
another portion of the foetal lung (Observ. 1, 11, 15, 33). Another 
constant result of asphyxia in children, is a more or less marked de- 
gree of plethora and peripheric ecchymosis of the respiratory organs, 
and, in many cases, a remarkable repletion of the superficial pul- 
monary capillary vessels. These appearances are sufficiently ex- 
plained by the suction of the thorax, when enlarged by the action of 
the inspiratory muscles. These signs taken together, must be con- 
sidered a very valuable addition to forensic examinations. Another 
influence of disturbed fceto-placentar respiration, is a diminution of 
irritability by reflex-action ; it seems that the altered condition of the 
blood tends to weaken the general irritability of the foetus. This 
want of sensibility is always in accordance with the existent degree 
of asphyxy in still-born children. The most important symptom of 
foetal asphyxia, is the diminished activity of the heart, perceptible 
before delivery is completed, it is equally valuable for diagnosis 
as for prognosis and treatment. With regard to the influence of 
labor upon the condition of the foetal pulse, Dr. Schwartz came to the 
following conclusions, based upon a large number of personal obser- 
vations : In all cases of normal labor, the frequency of the foetal 
pulse remains unaltered from the first beginning, up to the termina- 
tion of labor. In by far the greatest number of cases, the foetal heart 
offered 144 strokes in a minute ; in one instance it was 180, in 
some few 120. Circumstances, which are apt to modify the pulse, 
are — movements of the foetus, pressure by uterine contractions, and 
paralysis of the heart from asphytic intoxication. A sufficiently 



158 

strong pain has generally a retarding influence upon the foetal heart, 
while in many cases, the foetal pulse is not at all altered in frequency 
during the pains. With the remission of the pain, the pulse acquires 
its former frequency, but if the pulse continues slow after the pain is 
over, this must be considered as a sign of existing danger for the 
foetal life. A lasting, gradual, or sudden decrease of the foetal pulse, 
is always the consequence of beginning asphyxia, and must be con- 
sidered as the most reliable sign of approaching death. This sudden 
paralysis of the foetal heart, is always observed in those cases where 
the union between mother and child is entirely annihilated, as it hap- 
pens in cases of early detachment of the placenta, or of a sudden and 
lasting compression of the cord. The results of Dr. Schwartz's 
researches on the signification of the early passage of urine and 
meconium, may be comprised in the following : 1. With children 
who die during or immediately after labor, or with those who are 
still-born and afterwards revived, the early passage of excrements is 
the rule, and is observed more frequently among the former class. 
2. Both meconium and urine are altogether, under equal circum- 
stances, more often early discharged in girls than in boys. Neither 
the state of development, nor the presentation of the foetus, nor the 
conditions of the soft parts, seem to have ceteris paribus, a decided 
influence upon the early passage of urine or meconium. From this it 
appears that the principal influence upon this discharge, must be 
sought in a modified vitality of the foetus, it is always an indication 
of approaching danger for the life of the child. All the different 
symptoms have to be taken into account, when we attempt to form a 
prognosis with regard to the ultimate safety of the child, and, above 
all, we have to watch the different changes occurring in the pulsa- 
tions of the foetal heart ; we have to watch its strokes from the very 
first beginning of labor, because in this way alone we will be enabled 
to acquire a satisfactory judgment of the true condition of the 
activity of the heart. The indications to be fulfilled, whenever the 
life of the child seems to be in danger, are twofold ; first, to reestab- 
lish the interrupted foeto-placentar circulation ; secondly, if this 
be out of our reach, to repair it by athmospheric respiration. The 
first demand can only be complied with in cases of prolapsed funis, 
and a reposition must be attempted in all cases where the pulsations 
are not below 60 or 10 in a minute ; in the latter instance, the author's 
experience has convinced him, that the only safeguard for the foetal 
life, is a speedy delivery. Mechanical interference, moreover, is 
called for in all those cases where the paralysis of the foetal heart is 
going on steadily in consequence of all those other causes, which are 
apt to suppress a sufficient exchange of oxygenized blood. The 
treatment of children born in an asphyctic condition, consists in en- 
gaging and strengthening inspiratory movements, and in removing 
such obstructions, as might be apt to prevent them. 

A very valuable addition to our knowledge of uterine and vaginal 
rupture, is Dr. Lehmann's article on this subject. From an exten- 
sive private and hospital practice, the author was enabled to collect 
forty-one cases of rupture of the womb and the vagina. With re- 
gard to their cause, Dr. Lehmann divides the ruptures into three dif- 



159 

ferent classes, calling them spontaneous, accidental, and mechanical. 
In by far the greatest number, the predisposing cause of laceration 
is due to a morbid condition of the texture of uterus. From a com- 
parison of eleven observations, reported in this article, with the 
opinions of other authors, Dr. Lehmann comes to the following con- 
clusions. The location of the rupture is generally confined to the 
place, where the uterine walls are thinest, viz., near its lower seg- 
ment, and in some exceptional instances, near the fundus. According 
to the disposition of the muscular fibres, the lacerations run in a di- 
agonal, or in a horizontal direction. In some cases the rupture is of 
a very small size, especially when it was caused by gangrena from 
pressure, be it against the promontory, or a sharp osseous edge, or a 
spina (pelvis spinosa Kilian). In incomplete, non-penetrating rup- 
ture, the uterine wall is only partially destroyed, while the uterine 
cavity remains closed. The remark, that uterine ruptures happen 
more often in deliveries of male, than in female children, is confirmed 
by Dr. Lehmann's observations. The first symptom of a rupture is 
generally a violent and sharp pain, experienced by the parturient 
woman ; she cries out vehemently, expressing^her sensation as if some- 
thing had given away internally. Soon after this, labor comes sud- 
denly to a stand still, and a more or less considerable quantity of 
blood issues from the vagina ; the patient has fainting spells, the 
features have an expression of greatest anxiety, the pulse becomes 
rapid, very thin, extremities cold and dyspnoea, orthopnoea, vomiting 
of dark or bloody matters, seldom fail to make their appearance. 
Sometimes irregular pains return with short intermissions, while the 
presenting part of the foetus is drawing back, instead of advancing. 
Drs. Kiwisch and M'Clintock have mentioned a rapidly developing 
emphysema among the prominent symptoms of rupture. In by far 
the greatest number of cases, death follows soon after the accident, 
and this same result often accompanies partial, non-penetrating rup- 
tures, owing, as it seems, to the shock produced by the lesion of the 
organ on its hight of physiological development and activity. Two 
cases are reported, where ruptures of a considerable extent, allowed 
the mothers to recover. With regard to treatment, Dr. Lehmann 
strongly advocates the operation of turning, in cases where the head 
is floating high above the brim of the pelvis, and gastrotomy in cases 
where a living child is deposited entirely in the peritoneal cavity. 
The placenta ought to be left in the womb, if it cannot be removed 
very easily. Against the hemorrhage and anaemia, cold fomentations 
of the abdomen, analeptica, mineral acids, etc., have to be adminis- 
tered. 

Dr. M'Clintock draws attention to a symptom observed in a case of 
ruptura uteri, which he thinks, might hereafter be found of value 
as a diagnostic of laceration of the uterus or vagina. This symp- 
tom was an emphysematous state of the integuments covering the 
hypogastrium. Its existence was detected by the stethoscope while 
searching for the foetal heart. Examined for in this manner, the cre- 
pitation was loud and distinct, but to the touch it was not so obvious, 
except when firm pressure was made in the proper situation, then 
the crepitus was evident, and was recognized by Dr. Montgomery, 



160 

and by several pupils, who happened to be present. Upon 
post-mortem examination, the left broad ligament was found emphy- 
sematous, and a tear existed in the left side of the uterus, at the junc- 
tion of the body and cervix. At some distance from this, the peri- 
toneum was also lacerated, and a considerable quantity of blood 
had been effused into the abdominal cavity. 

Dr. Dillon describes a case of uterine rupture, in which the 
rent was so large, that the margin of the liver and a mass of small 
intestines found entrance through it into the cavity of the uterus. 

Dr. Mora)RET,.in his general remarks on the causes of death, as- 
signs to them a triple seat u viz., the brain, the heart, or the lungs, the 
former organ always being primarily or secondarily affected when 
death occurs, as it is the seat of the vital principle. Death may be 
brought on by a material and traceable, or by a dynamic lesion of 
one or more of these central organs. The shock received may be so 
severe as to prove fatal, or a comparatively slight injury may com- 
bine with a preexisting cause, to produce the fatal result. 
First of all, the digestive organs, at the very beginning of preg- 
nancy, are at times the seat of considerable morbid affections, and 
some cases of sudden death came to Dr. Mordret's notice, which 
seemed to be owing to undue irritation of the alimentary canal ; in 
one instance by a strong cathartic, in the other instance by the re- 
ception of an unusually large quantity of food. The chemical com- 
position of the blood during pregnancy being characterized, by the 
diminution of red globules and of albumen, by the increased quantity 
of fibrin, phosphates, fat, and water, is one great source of patholo- 
gical phenomena. The author thinks, that the physiological condi- 
tion of the foetus during the first months of gestation, demands an 
impoverished blood for its maintenance, and that the troubles from 
the digestive organs, such as vomiting, dislike of certain eatables, 
very properly tend to the formation of a blood thus qualified. The 
increase of fibrin in the blood of pregnant women is explained by 
the enormous growth of the uterus, which demands this constituent 
for its development, and nature endeavors to supply it. The diminu- 
tion of the albumen may possibly be explained by the fact that part 
of it is changed into fibrin, with which it is isomerous, but it is more 
natural to attribute it to the constant drain to satisfy the demand of 
the foetus. — The author's logic is not clear, nor are his deductions cor- 
rect in such statements as these. The increasing uterus demands 
fibrin, and, therefore, the blood contains more fibrin ; and the foetus 
demands albumen, hence the blood contains less albumen, than un- 
der ordinary circumstances. — E. N. The increase of water is ex- 
plained by the great want of water for the annexes of the foetus. 
The bearing of this abnormal state of the blood upon the 
chances of sudden death, consists in the general debilitated con- 
dition of system arising from this source, while the increase 
of fibrin tends to favor inflammations and coagulations of blood 
in the heart or the vessels. The increase of albumen and 
water explains the frequency of hemorrhages and serous effu- 
sions. The disturbances in the circulation, which may lead to sud- 
den death after and before delivery, take their rise from irregular 



161 

distribution of the quantity of blood present at certain moments, or 
from compression of the large abdominal veins. Among the preter- 
natural secretions the author mentions, ptyalism, night sweats, and 
albuminuria. The latter condition (albuminuria), is treated in a few 
lines, and Dr. Mordret thinks that the presence of albumen in the urine, 
is of no etiological importance in regard to sudden death — we feel 
obliged to be of the opposite opinion, considering Bright's disease 
and its consequences, as the most frequent cause of sudden death in 
child-bed, except that coming from hemorrhage. — E. N, The innerva- 
tion during pregnancy is often weakened, be it by the anaemic condi- 
tion of the blood, or by the different sufferings, to which women are 
subject during labor. 

An affection of the respiratory organs is one of the most frequent 
causes of sudden death. The lungs are predisposed to morbid at- 
tacks, by the pressure they have to suffer from the growing uterus, 
and by the compression of the large abdominal veins ; while on the 
other hand an impoverished blood circulates through them, by the 
presence of which, their contractility is diminished . This is exempli- 
fied in a case by Devilliers, published in the Revue Medicale, where a 
woman died suddenly, during labor, after a severe syncope. The 
post-mortem examination showed a splenified condition of both lungs, 
the head was not opened. In another instance reported by Dr. De- 
villiers, the lesions found in the body, were cartilaginous induration 
of the mitral valve, oedema in the apex of the right lung, apoplexy 
in the inferior lobe of the same side, infiltration of the apex of the 
left lung and red hepatisation in the inferior lobus of the left lung, 
considerable quantities of serum in both pleural cavities. (This was, 
doubtless a case of embolia, E. N.). A similar observation, but 
without post-mortem examination, has been published by Dr. Aran, 
in the Bulletin de Therapeutique. A case of sudden death in conse- 
quence of a double pleuro-pneumonia, is mentioned by Dr. d'Ollivier 
d' Angers. The following case, reported by the author as one of sudden 
death from pleuritis, is clearly one of Bright's diseases ; the autopsy 
is minutely reported, with the exception of the condition of the kidneys. 
A case of sudden death after confinement, from asthma, is reported 
by Dr. Delamotte. Another cause of sudden death, is the rapid de- 
velopment of emphysema pulmonum during labor. According 
to Drs. Cazeaux, Leroy d'Etiolles, and Piedagnel, compression of 
the lungs from outside, or by the elevation of the diaphragm, 
(Dr. Lerrat) may lead to fatal asphyxis. Sudden death from an af- 
fection of the heart, arises mostly from a sudden bodily or mental 
shock, or a trouble in the circulation, when combined with a pre- 
vious disease of this organ. Dr. Pelago gives a description of a case 
of sudden death from rupture of an aneurism in the last stage of la- 
bor (Gaz. Med., 1841). Similar cases are recorded by Drs. Cazeaux 
and McNicholl. Dr. Corvisart has observed a case of sudden death 
after delivery, from a sero-purulent pericarditis. The chief symp- 
tom of an affection from heart disease is the syncope, which, however, 
may seize a woman during confinement, while the heart is perfectly 
sound. In both instances the accoucheur has to shorten labor artifi- 
cially, be it by instruments or by simply rupturing the membranes, 
11 



102 

thus establishing a freer circulation. Under the head polypiform 
concretions of heart and the large vessels, three observations are 
recorded, one by Kieth, one by Havens, and that of the Duchess of 
Namour. Dr. Mordret considers the great quantity of fibrin in the 
blood of pregnant women, and accidental hemorrhage, as the principal 
causes in effecting these concretions. 

Sudden death may be caused by the spontaneous production of 
gas in the blood-vessels, or by the artificial introduction of air 
into the system. The first cause is sufficiently demonstrated by the 
observations of Drs. Ollivier (d'Angers), Devergie, and Durand-Far- 
del. One of Ollivier's cases is communicated. A young woman, 
nearly nine months pregnant, died suddenly, with the signs of a vio- 
lent dispnoea. Post-mortem examination forty-eight hours after 
death. No alteration of importance to be found, but gas mixed in 
considerable quantity with the blood of the subcutaneous veins of 
the chest, which escaped with a whistling noise, upon incision ; cavi- 
ties of the right heart considerably enlarged, no clot inside. Lungs 
and brain healthy. An interesting observation of Dr. Durand-Far- 
del is added, where a non-pregnant woman died suddenly, while 
taking a bath, from spontaneous development of gas in the blood, as 
exhibited by the post-mortem, performed twelve hours after death. 
Two similar facts, one of which is recorded by Dr. Devergie, are men- 
tioned by Dr. Mordret, who thinks that the predisposition for produ- 
cing gas in the blood, during the pregnant state, is due to the anae- 
mic condition of the blood. The entrance of air through the uterine 
veins has been demonstrated beyond doubt. Dr. Legallois has des- 
cribed this accident in animals, one of which was starved for the 
sake of an experiment, while two others were profusely bled. Two 
observations are recorded by Baudelocque ; in both a hemorrhage 
preceded death, and gas was found in the heart and the large veins, 
although the autopsy was performed only five or six hours after death. 
Dr. Nelaton, while making an injection into the uterus of a dead 
woman, saw the injected mass enter one of the veins of the ligamen- 
tum latum, pushing a quantity of air-bubbles before itself. Dr. 
Bessems communicated a similar fact to the Sociele de Medicine d'An- 
vers. In the latter instance a woman died after an injection of aqua 
oxymuriatica into the womb, and afterwards air was found in the 
heart and in the vena cava. Drs. Wintrich and McClintok have pub- 
lished several observations, proving the entrance of air into the uter- 
ine veins. The air absorbed by the uterine veins may be atmospher- 
ic air entering the uterus while in a relaxed state, or putrid gases 
formed from decaying matters in the womb. The entrance of air 
into the system is the more dangerous, in proportion as the quantity 
of blood is diminished by previous losses, a fact sufficiently proven 
by experiments upon animals, and thus, sudden death, after a com- 
paratively small hemorrhage, may be caused, in some instances, by 
the entrance of air into the uterine system. The symptoms of en- 
trance of air into the system, are a characteristic noise, a deep syn- 
cope, extreme paleness, pulse and respiration imperceptible, and 
death soon afterwards. In these cases treatment of course is out of 
the question. We are sorry to find the author perfectly ignorant, 



163 

as it seems, of the important theory raised by Frerichs, regarding 
the connection of Bright's disease, with the presence of carbonate of 
ammonia in the blood of pregnant women. Among the lesions of the 
nervous centres, apoplexy is the most frequent affection causing sud- 
den death. Dr. Mordret favors the opinion, that pregnancy and labor 
bear in themselves a predisposition to cerebral affections, a fact, de- 
nied by Dr. Negrier. This predisposition is attributed to the com- 
pression of large veins and arteries from the womb, as well as from 
the contraction of muscles during labor-pains. Sudden death from a 
latent puerperal fever has been frequently observed. Dr. Dubois 
describes a case of sudden death from a latent sero-purulent peri- 
tonitis and lymphangitis in the Journal de Medicine pratique, art. 
2832. Drs. Sundelin and Delamotte have published similar observa- 
tions. Death following upon these accidents is explained by the de- 
pression of the ganglionic system. 

Sudden death without any pathological lesions may be caused 
by a nervous apoplexy, by a syncope, or by an idiopathical 
asphyxy. As a sample of nervous apoplexy, the author men- 
tions a case of puerperal convulsions, followed by a deli- 
rious and comatous state, which is described by J. Frank; the woman 
was saved by the use of stimulants. Interesting cases of lethargy, 
from which the patients recovered accidentally, are those of Ph. Peu 
and Puigandeau. In the Abeille Medicale Dr. Poe'lman has published 
an interesting observation of nervous apoplexy fourteen days after 
confinement; a perfect paralysis of the right side, and all the other 
symptoms disappeared in a few hours, while a trouble in the speech, 
and absence of the radial pulse in the right arm, continued for some 
time. Other cases of nervous apoplexy are recorded by Drs. Dax 
{Abeille Medicale, 1849) and Artaud {Revue. Ther. du Midi., 1850). Sud- 
den death in these instances, is very often prompted by a wrong 
medication, in consequence of a wrong diagnosis. The differential 
diagnosis is taken partly from the antecedents, partly from the ac- 
tual condition of the patient. It generally occurs in lymphatic, deli- 
cate, nervous, and hysteric women ; the face is pale, pulse feeble, par- 
alysis and coma are generally of short duration, often alternating with 
convulsions. Idiopathic asphyxy and nervous syncope are accidents 
which kill rapidly without any appreciable cause. In the first instance 
death occurs by the sudden suspension of respiration, its first and chief 
symptom is asphyxy, while idiophathic syncope are called those 
cases where the action of the heart is primitively suspended. A 
common character with both these affections and nervous apoplexy is 
the want of anatomical lesions. The heart is generally found empty, 
and in two observations the vena cava was in a state of vacuity, 
while in many instances the heart was far advanced in fatty degen- 
eration. Many cases of death from syncope are doubtless ow- 
ing to the exhaustion of the system from exceedingly violent 
pain after protracted confinement. Three observations illustra- 
ting this explanation are offered by Dr. Delamotte {obs. 218 
and 389), one by Dr. Moreau {traite d'acouchements lorn, ii.), and one 
by Dr. Mordret himself. Besides pain, a violent mental emotion, 
may cause sudden death. Dr. Peu mentions several instances, 



164 

where anger had a disastrous effect upon women in confine- 
ment. More than anger, fear is to be dreaded in its influence up- 
on the patient, and many fatal cases are owing to this latter circum- 
stance, as Dr. Frank had ample occasion to witness. The author 
gives the history of a woman who died suddenly, after an easy con- 
finement from the annoyance she experienced, when she learned that 
her offspring was a girl, instead of a boy, as she expected. Still this 
case is not so very striking, as, besides a considerable hemorrhage, 
the placenta was not removed for six hours after delivery. Several 
other lesions existed, an enormous tympanitis, distension of the heart, 
uterus, stomach and intestines by gas ; bloody serum in the pelvic 
cavity, hypostasis in the lungs, and so on. The observation is taken 
from Morgagni. Dr. Travers has noticed a case of sudden death after 
an easy confinement, in a lady, who, during the whole of her pregnan- 
cy was impressed with the idea, that she was bound to die in child-bed. 
The post-mortem discovered no anatomical lesion whatever. The 
observations taken from Dr. Gartlan is all but conclusive — abdominal 
pains and tympanitis were present, no post-mortem had been per- 
formed, and still the case is considered among those of sudden death 
from fright. The observation of Delamotte (observation 230) is of no 
greater value, as .no autopsy is mentioned. To the 106th observation 
of the same author, we must make the same objection. A woman 
was frightened by a disagreeable nightmare three days before deliv- 
ery; when the child and afterbirth were extracted, they were found 
in the highest degree of petrification ; no autopsy. The following 
observation communicated by a midwife, who at the time of the 
occurrence, ten years ago, had no knowledge whatever of midwifery, 
is of no value at all. As an instance of death from protracted chill, 
the 21th observation of Madame Lachapelle is mentioned, although 
it was proven by the post-mortem that " all the serous membranes, 
but more particular the peritoneum, were bathed in a sanguinary 
liquid, while the entire blood was exceedingly thin and watery." 
Under the head of "fatal chUl," another observation of Madame La- 
chapelle is put down, which is clearly nothing but a rapid peritonitis. 
Dr. Mordrkt says that nervous syncope is often the result of a 
gastric irritation, similar to the syncope of old men, from the same 
cause, and he thinks that the immediate cause of death, in similar 
instances, comes from a paralysis of the ganglionic system of the 
abdomen. Cases of sudden death shortly after delivery, without any 
anatomical lesions, are reported by Drs. McClintok, Chevalier, Davis, 
Denman, Sandras, Chailly. In some of these observations, an insig- 
nificant hemorrhage preceded death, and Dr. Mordret very justly 
remarks, that a violent hemorrhage is at times well enough supported 
by otherwise strong women, while even a slight hemorrhage after a 
protracted and painful confinement, is sufficient to cause death. Most 
of the observations here reported are — as it appears to the writer — 
perfectly valueless, owing to the absence of post mortem examina- 
tions. Sudden death not only occurs immediately after or during 
labor, but in some cases, a great while afterwards. Dr. Robert has 
communicated to the Societe de Chirurgie four cases of sudden death, 
of which one occurred nine days, two sixteen days, and one twenty 



165 

days after a normal confinement. Only in the last case the autopsy 
was performed, but nothing worth notice was found, besides slight 
vascularisation of the pericardium, in the cavity of which, a spoon- 
ful of serum was found, the heart was somewhat more fatty than 
usual. In treating of the condition of women after delivery, Dr. 
Mordret very justly remarks, that the strict diet, as recommended by 
physicians in France, at this period, is, as a general rule, more inju- 
rious than beneficial, inasmuch as it tends to prolong the constitution 
of blood peculiar to pregnant women, viz., ansemia. 

Dr. Villeneuve has published an observation in the L } Union 
Medicate, where a woman died suddenly on the twenty-sixth day 
after her delivery, after an access of tumultuous movements of the 
heart ; no autopsy. Dr. McOlintok records two cases of sudden death 
a few days after delivery ; the post mortem examinations revealed 
nothing, but an anormal flaccidity of the heart, with complete 
absence of blood in its cavities, which condition Dr. Mordret attrib- 
utes to an angemic state of the blood. 

In summing up, Dr. Mordret reviews the different causes of death 
before, during, and after confinement, and comes to the following 
conclusions : 

1. If a woman dies suddenly during the puerperal .period, it is* 
very probable that her death was owing to this condition, an organic 
lesion producing death being present or not. 

2. If a woman dies suddenly during confinement, a latent organic 
lesion may have existed before she became pregnant, or it may have 
been developed under the influence of pregnancy. 

3. The introduction of air into the uterine veins is possible shortly 
after delivery. This introduction of air is a material cause of sud- 
den death, which must have escaped recognition in many instances. 
The spontaneous development of gas in the blood seems to be favored 
by the puerperal state ; but the facts known are not sufficiently con- 
clusive. 

4. It seems very likely, that the puerperal state predisposes to 
sanguinary concretions in the heart and the large vessels, a material 
cause of death very often not appreciated. 

5. The chloro-ansemic condition, very frequent in pregnant women, 
seems to favor sudden death ; it is at least a weakening influence, 
which is apt to diminish their vital resistance. 

6. All weakening influences seem to predispose women in childbed 
to sudden death ; it seems, at least, that this accident has been ob- 
served more frequently in multiparous women, than after the first 
confinement, and more often in lymphatic and nervous, than in robust 
persons. 

T. Every instance of sudden death, which cannot be explained by 
an anatomical lesion, seems to^be the result of a nervous affection, 
which may have its starting-point in the cerebro-spinal or in the 
ganglionic system. 

8 . The pernicious effects of pain, of mental emotions, of an unfit 
diet, etc., are incontestable in pregnant women. In every one of 
these circumstances, the nervous element is severely affected, and 
many cases of sudden death may be the result of one or more of 
these same circumstances combined. 



166 

Dr. Marc d' Espine's treatise contains a statistical analysis of deaths 
occurring during, or shortly after delivery, from which he concludes, 
that the large lying-in hospitals were dangerous institutions for the 
safety of mothers, and he, therefore, recommends to have the women 
delivered in private dwellings. 

In a case attended by Dr. Thornton, the mother died suddenly 
while in labor from some unascertained cause. Forty minutes 
elapsed after the patient's death, before Dr. Thornton arrived. On 
examination, he found that the membranes had been ruptured, 
that the head was in the cavity of the pelvis, the vertex presenting 
at the inferior strait. Dr. Thornton raised the foetal head, passed the 
hand into the flaccid womb, turned the child, and extracted it as far 
as the head without delay ; at this point it momentarily hung until 
assisted by the fingers in its mouth. Thus forty-five minutes elapsed 
from the last expiration of the mother to the complete extraction of 
the child. The child did not breathe, and was of a blueish color ; but 
a slight ticking could be heard on placing the ear over the heart. 
t The fauces were cleared, Marshall Hall's ready method then diligent- 
' ly practiced for half an hour, when a convulsive inspiration took 
place. This method was persevered in, assisted by aspersions and 
frictions, and v at length respiration was established. The child, a 
boy of the average size, sucked vigorously at the bottle, and lived 
for three weeks and two days ; its death probably resulting from 
want of sufficient care. 

Dr. Rigby ventilates the question, what position a woman would 
assume, when left alone during labor ? From the history of older 
times it appears, that women used to sit or kneel down. Dr. White, 
of Manchester, was the first who proposed to place parturient women 
on one side, as the most natural and most comfortable position for 
delivery. Dr. Naegele left a young primiparous woman entirely to 
herself in a room, which contained several chairs, one delivery-chair, 
one sofa, and one bed. During the first part of labor she adopted 
several attitudes, leaning against the wall, stooping over a chair, or 
on the sofa. Towards the end of labor she first lay down upon the 
sofa, then on the bed, where she remained. Here she threw herself 
around, now on her back, now on one or the other side ; but when 
the head began to pass the external orifice, she took to lying on the 
left side, in which position she remained till all was over. This 
experiment induced Dr. Naegele to choose the left side as the most 
convenient position for women in labor. 

Dr. Klopsch analyzed a lithopaedion, with a view to examine 
into the nature of a regressive metamorphosis, which presents the 
most physiological features of an entire organism undergoing retro- 
grade changes, under the most perfect seclusion from the atmosphere. 
The specimen, taken from the womb of a cow, is rather a dermatopae- 
dion, than a lithopaedion ; a corrugated, indurated foetus, without 
calcareous deposits. The uterus from which it was taken exhibited 
not the slightest trace of cotyledones or placentar formation. The 
inside of the uterus, as well as the foetus were covered with a thick, 
yellowish-brown substance, which, on chemical analysis, appeared to 
be a mixture of melanin, haematosin, fat-drops of a reddish color, and 



167 

crystals of haemotoidin. This substance must be considered as the 
remnants of an hypertrophy of the entire mucous membrane, which 
condition is explained by the absence of cotyledones or placenta. 
The fleshy parts of the foetus were as hard as leather, containing a 
yellow, thick, fatty matter, to a great extent, but no earthy salts ; all 
the intestines covered with fat ; the greatest portion of the cranium 
filled with white or yellow fat ; the brain, very much reduced in size, 
was a solid, dry, fatty mass ; the organs contained in the thorax and 
abdomen very hard, dark, and covered with fat. A microscopical 
examination of the epidermis and chorion gave proof of their perfect 
integrity. The muscles had undergone fatty degeneration ; the fat 
could be traced between the sarcolemma and the primitive bundles, 
while the proper contractile muscular substance remained intact. 
The tendons and fibrous membranes, dura mater, cartilages, and 
bones, were perfectly normal in structure — no fatty or calcareous 
metamorphosis. The heart was a solid, hard body ; the vessels con- 
tracted and perfectly empty, with the exception of the larger venous 
sinuses of the head, which were filled entirely with a fatty substance, 
consisting of fat without fatty acids, and a very small quantity of 
earthy salts. The presence of this enormous quantity of fatty blood 
the author explains as well from the absence of the placenta, an 
organ intended for oxygenizing the foetal blood, as from the great 
amount of fatty matter from the blood of the mother. The microsco- 
pical elements of the brain and spine were unchanged, but both 
replete with fat and cholesterin. 

Dr. Hall remarks that ulcerative inflammation of the mouth does 
not unfrequently appear in women during the closing months of 
utero-gestation. It is rarely met with in particular localities, while 
in others it seems to be endemic. The affection seems to be of an 
aphthous nature, and associated with a disordered system, as that of 
anaemia combined with a scrofulous diathesis, dyspepsia, etc. It 
attacks the mucous membrane indifferently, and is even migratory 
in its character. It sometimes becomes chronic. The treatment 
consisted of astringents, acids, and tonic medicines. 



IV.— PATHOLOGY OF THE OVARIES. 

1. Peaslee, E. R., on Two Successful Cases of Ovariotomy by the Large 
Abdominal Section. — Amer. Jour., LXXII. Oct. 

2. Atlee, J. L., Removal of an Ovarian Tumor with the Ecraseur. — 
Amer. Med. — Chir. Eeview, July. 

3. Hewitt, Ch. N., Successful Case of Ovariotomy ; Performed by Dr. 
H. E. Potter.— Amer. Jour., LXXII., Oct. 

4. Nelsbn, R., a Case of Ovariotomy Successfully Performed. — Amer. 
Monthly, July. 

5. Humphrey, Case of Successful Ovariotomy. — Med. Tim. and Gaz., 
June 12. 

6. Spencer Wells, Cases of Successful Extirpation of (multUocular) 
Ovarian Cysts. — Med. Tim. and Gaz., 426, Aug. 28 ; 431, Nov. 13 ; 
441, Dec. 11 ; 332, March. 



168 

t. Hutchinson, Three Cases of Polycystic Ovarian Tumor ; Ovariotomy. 
— Med. Tim. and Gaz., 440. 

8. Case of Ovariotomy ; Death. ( Under the care of M. Erichsen.) — 
Med. Tim. and Gaz., 441, Dec. 11. 

9. Polycystic Ovarian Dropsy — Ovariotomy — Death from Peritonitis 
on the Fourth Day. ( Under the care of M. B. Childs.)—Med Tim. 
and Gaz., 441, Dec. 11. 

10. Barnes, Statistical Bemarks on Ovariotomy. (Read before the 
Western Med. Soc. of London.) — Med. Tim. and Gaz., June 12. 

11. Simon, G., an Analysis of Sixty-one Gases of Ovariotomy Performed 
in Germany. — Scanzoni, Beitr. zun Geburtsk., etc. B. 3. 

12. Boinet, on Injection of Iodine in Ovarian Dropsy. — Rev. de ther. 
me*d. — chir. 1. 

13. Lacroix, Ovarian Cyst developed simultaneously with Gestation — 
Radical cure by one Injection of Iodine. — Bull, de Thdr., June 15. 

14. Warin, Three Gases of Ovarian Dropsy ; Injection of Iodine; All 
Cured. — Gaz. des Hop., 111. 

15. Sausset, on Injections of Iodine in Gases of Non-Purulent Ovarian 
Cysts. — Rev. de ther. mdd. — chir. 4, 5. 

16. Bickermann, Ovarian Dropsy treated by Injection of Iodine. — Med. 
Tim. and Gaz., 415, June 12. 

It. Brower, T. H., Two Cases of Ovarian Dropsy Successfully Treated. 
Chicago Med. Jour. 

18. McDaniel, R., on Tapping in Ovarian Dropsy. — New Orleans Med. 
News, Aug. 

19. Oppolzer, Ovarian Dropsy Cured by Puncture of the Cyst. — Wien. 
Wochenbl. 32. 

20. Death after Paracentesis of an Ovarian Cyst. — Med. Tim. and Gaz., 
415, June 12. 

21. Lumpe, E., Ovarian Cyst Cured Spontaneously by Bupture into the 
Bectum. — Wien. Ztschr., May 31. 

22. Melhose, A. L., Dissertatio de tumoribus ovariorum cysticis, adjecta 
morbi historia. — Gryphiswaldae. 8, p. 51. 

— Melhose, Thesis on Cystic Ovarian Tumors, etc. 

23. Pernod, 0., Essay sur les kystes de Vovaire, consideres surtout au 
point de vue du traitement. These. Strasbourg : Benger-Levrault, 4, 
pp. 62. 

— Pernod, Thesis on Ovarian Cysts, Especially urith Begard to Treat- 
ment, etc. 

24. Jacob, P. E., Nounulla de ovariorum tumoribus difficile dignoscen- 
dis. Gryphiswaldae 8, pp. 32. ( , 

— Jacob, Thesis on Ovarian Tumors with Begard to Diagnosis, etc. 

25. Driver, V. G., Beport of a Case of Ovarian Dropsy with Malignant 
Disease of the Uterus. — Lancet II., 4, Oct. 

26. Friedreich, N., Compound Dermoid Ovarian Cyst with Vibratile 
Epithelium and Formation of Nervous Tissue ; Constitutional Syphilis, 
Extensive Amyloid Degeneration. — Virchow's Archiv., XIII. 4, 5. 



169 

21. Keichel, H., Dissertatio • de ovarii carcinomate, subsequenti carcino- 
mate secundario uteri, hepalis et omenti. — Gryphiswaldse 8, pp. 29. 

— Reichel, Thesis on Carcinoma of the Ovary with Secondary Carcino- 
ma of the Uterus, Liver, etc. 

28. Guersant, Double Hernia of the Ovary. — Gaz. des Hop., M. 

29. Faunet, Ovaritis with Formation of Pus ; Artificial Opening of the 
Abscess above the Arcus Pubis. — Jour, de Toul., Jan. 

30. Differential Diagnosis of Hydrops Ovarii and Hydrops Ascites. — 
Med. Tim. and Gaz., June 5. 

The most important article, with regard to ovarian disease, is Dr. 
Simon's analysis of cases of ovariotomy performed in Germany, which 
reveals a frightful rate of mortality. In opposition to this we are 
happy to report a considerable number (14) of operations, performed 
exclusively in England and America, the favorable result of which is 
partly owing to a modification of the method, hitherto followed, with 
regard to the management of the peduncle. For this the profession 
is indebted to Drs. Atlee, Hutchinson, and Wells. The cases of 
ovariotomy are thus distributed : Hutchinson, 4 ; Wells, 4 ; Brown, 
2 ; Peaslee, 2 ; Atlee, 1 ; Nelson, 1 ; Hewitt, 1 ; Humphrey, 1 ; 
Erichsen, 1 ; Childs, 1. Of the eighteen, fourteen recovered and four 
died. In two cases the tumor was *fbt removed ; both patients died. 
In eight cases the end of the peduncle was brought out externally ; 
in one it was severed by the 6"craseur ; of these seven recovered. 
Most of the cases were polycystic, and had firm adhesions. The 
account of operations published by Dr. Peaslee is sufficiently inter- 
esting to justify a somewhat lengthy abstract. 

I. — In the case of Miss Susan K. Russell, the operation of paracen- 
tesis was performed, preliminary to settling the question of the pro- 
priety of removing the mass of the tumor, which was evidently mul- 
tilocular. After thirty-four pounds of fluid were removed from the 
two larger sacs, the mass could be moved somewhat in the cavity of 
the abdomen. The patient was in a very debilitated state (she had 
been tapped nine times previous to this), and so it .was decided to 
give her the only remaining chance of living, viz., by the operation 
of ovariotomy. 

Before commencing the operation the atmosphere of the room was 
rendered moist by the evaporation of water, and kept at a tempera- 
ture of 80° F. The patient being under the influence of sulphuric 
ether, an incision was made through the abdominal walls, eight 
inches long. The tumor was found to be firmly adherent everywhere 
anteriorly above the level of the umbilicus, and by strong bands also 
to the stomach, the omentum and the right iliac fossa. Commenc- 
ing, however, below the umbilicus, the hand, previously immersed 
in artificial serum at a blood heat (composed of water §iv. ; white of 
eggs, 3vi., and common salt 5iv.), was introduced and forced up 
between the tumor and the parietal peritoneum, thus tearing away 
the adhesions. This was effected slowly, since, in most of their ex- 
tent, the operator's whole strength was repeatedly applied before 
accomplishing the object. Prof. Peaslee attempted to separate the 



170 

adhesions at their inner extremity (that in contact with the tumor), 
in every part, so that if any hemorrhage ensued, the bleeding vessels 
could be easily ligated. No ligature was however required, though, 
for a few minutes, there was a general oozing of blood over the 
whole surface. Next, the tumor was lifted out of the abdomen, and 
a double ligature of four threads of saddler's silk, waxed, but not 
twisted, was passed through the middle of the pedicle ; each portion 
was tightly tied round its respective half of it, and the latter was 
then divided. The pedicle (*l" wide) was so short, that the ligature, 
when tied, came in contact with the tumor. The operator, therefore, 
cut it through to the substance of the* tumor on both sides of the 
latter, at the distance of one-third of an inch from the ligatures, and 
dissected out the lower portion of the tumor from between the two 
layers of the .pedicle. The tumor was a mass of sacs, containing 
fluids of different shades. The clots of blood and the remaining fluid 
were carefully removed with a fine sponge from the pelvis. 

The incision was now closed by nine needles and six sutures ; the 
two ligatures were brought out below the lowest needle at the end 
of the incision ; a compress, wrung in blood-warm water, was 
applied and covered with oiled silk. The temperature of the room is 
to be kept at 10° or 15° Fah. ; none but the water-dressing is to be 
applied, this being changed once in six hours ; panada, milk-porridge, 
or broth, for nourishment ; and stimulants and opiates to be given 
as may be required ; the catheter to be used once in six hours. 

At the third day after the operation, the whole incision was united 
by first intention. The ligatures came away one three months, the 
other four months after the operation. The patient recovered per- 
fectly. In the course of recovery several abscesses formed in the 
subcutaneous areolar tissue, around and to the left of the liga- 
tures. 

II. — In the case of Mrs. Hannah Holt, a large tumor could be felt 
in the abdomen, apparently surrounded by fluid in the cavity of the 
peritoneum. After tapping the patient, thirty-four pounds of gelati- 
nous fluid were obtained, when it was decided that the remaining 
unusually solid mass was a diseased left ovary, quite firmly attached 
at several points by adhesions. On the- 28th of October, 1856, the 
tumor was removed by the large abdominal section. All the prepar- 
ations of the apartment were made as in the preceding case. After 
the patient was brought fully under the influence of ether, an inci- 
sion, eight inches long, was made through the parietes of the abdo- 
men, whereupon several pounds of fluid escaped from the peritoneal 
cavity. The tumor consisted of a number of small sacs, and it was 
firmly adherent above on the right side, and these adhesions were 
torn away. But, at the lower part of the tumor, were two adhesions 
on the left side and one on the right, so strong as to resist the opera- 
tor's whole strength in the attempt to tear them ; and as they were 
in the form of tendinous bands, three-quarters of an inch in diameter, 
a strong double ligature was passed through the centre of each, and 
tying each of its two portions round one-half of the band, the latter 
was divided. Thus, six ligatures had already been applied. To the 
pedicle, being but five inches wide, and nowhere more than one- 



m 

quarter of an inch thick, a double ligature of three threads of sad- 
dler's silk was applied, and the tumor removed. 

While attempting to tear the adhesions, the substance of the mass 
itself gave way at one part, and so much blood escaped among the 
convolutions of the alimentary canal, that at least three-quarters of 
an hour were spent in making sure of its entire removal, the exposed 
surface being all the while kept moist by the free application of the 
artificial serum. All the ligatures (two for the pedicle and six for 
bands divided) were brought out at the lower end of the incision. 

The tumor removed weighed nine pounds ; it being of the areolar 
variety, or a congeries of small sacs, connected together by a large 
amount of areolar tissue. Eleven pounds of fluid also were removed 
from the cavity of the peritoneum at this operation. With the 
exception of a cough and excessive flatulence, no unpleasant symp- 
toms occurred. The former one was relieved by opium, the latter by 
the application of the rectal tube. 

Dr. Peaslee insists upon the importance of the artificial serum in 
aid of this operation, and says he would not hesitate to keep the 
cavity of the peritoneum exposed to view for any required length of 
time. 

Dr. Atlee removed a multilocular cyst in the usual way, through 
a cut in the mesian line, and the pedicle was severed from the tumor 
by the ecraseur in six and a-half minutes, and the external wound 
closed up by silver sutures. On the seventh day the sutures were 
removed, the wound being united throughout the whole extent. From 
this day the patient sat up daily, and recovered perfect health. Dr. 
Atlee has performed ovariotomy seven times, but in none of his cases 
was recovery so rapid, and constitutional disturbance so slight, as in 
this last one, treated by the ecraseur and silver sutures, which were 
applied in such a way that the peritoneum was not touched. 

In the operations performed by Dr. Spencer Wells, he used a tro- 
car, contrived by Mr. Thompson, in the midst of the canula of which 
an elastic tube can be attached, so that the fluid is conveyed away 
quietly and neatly, without unnerving the patient. The pedicle was 
secured between the blades of a metal clamp (Dr. Hutchinson's sug- 
gestion), very much like Ricord's penetrated forceps for circumci- 
sion. 

In the third of Dr. Hutchinson's cases the free edge of the liver 
seemed to be depending into the upper part of the cyst, and, there- 
fore, any further attempt at removal was abandoned. 

At the annual meeting of the Western Medical and Surgical So- 
ciety of London, Dr. Barnes made some remarks with regard to the 
statistics of ovariotomy. He had been led to this subject by a case 
of unilocular cyst, in which he had lately successfully operated. 
Having given the details of this case, he adverted to his individual 
experience of operative proceedings for the radical cure of ovarian 
dropsy, which extended over 13 cases. In 8 of these the cyst was 
removed from the abdominal cavity ; in the remaining 5, the tumor, 
on account of adhesions could not be removed. Of the 8 removed, 
2 of the patients died from the immediate effects of the operation, 
and 6 recovered, showing a mortality of 1 in 4, or of 25 per cent. 



172 

Of the 5 cases in which the tumor could not be removed, all recov- 
ered from the operation, thus in the 13 cases the mortality was only 
2, or 1 in 6£. Dr. R. Lee's cases of ovariotomy were the most un- 
favorable ; but of 162 cases, 60 could not be removed ; in 5 of these 
no tumor was present ; of the 60 cases, 19 proved fatal, or rather 
less than 1 in 3. In the remaining 102, the disease was removed ; 
in 1 of these cases both ovaries and the uterus were excised, and in 
another the ovary, with part of the uterus, and in 2 cases both ova- 
ries ; of these 102 cases, 42 proved fatal, or about 1 in 2£. Dr. Clay, 
of Mancester, had had more experience. He had operated in 19 cases, 
and 55 proved successful, the mortality being about 30 per cent., or less 
than 1 in 3 ; so far as his experience went, the existence of adhesions 
did not interfere with the successful result. Dr. Atlee, of Philadel- 
phia, had operated on 36 cases, 12 of which were fatal, or 1 in 3. In 
13 cases, where the cyst was removed, occurring in the practice of 
Dr. F. Bird, 4 were fatal, or rather less than 1 in 3. In 21 cases re- 
corded in Ranking's Abstract, and Braithwaite's Retrospect, since 
the date of Dr. Lee's paper, 1 proved fatal, or 1 in 3. Hence, Dr. 
Barnes believed, that we were not only warranted in performing the 
operation in properly selected cases, but that it was our bounden 
duty to recommend it. 

Dr. Simon's review of operations performed by German surgeons 
has been prepared with a great deal of care and judgment, in order 
to establish the true value of the operation. It contains not only 
those cases which have been published previously, but besides, 23 
cases are added which were communicated to the author by private 
letters, mostly from the operators themselves. In reporting each 
case, he does not confine himself to short notices, but gives a history 
of every one of them. The results of the operations are divided un- 
der three heads, viz. : 1. Operations followed by a radical cure. 2. 
Operations resulting in death. 3. Operations from which the pa- 
tients recovered at first, the ultimate good result of which was only 
temporary, dubious, or of no consequence at all. In the latter divi- 
sion are counted those cases where the operation had to be given up 
in consequence of too strong adhesions or a wrong diagnosis, or 
where the patients died at a later period from the operation, or from 
the original disease. 

In all the former statistics (American, French, English) the cases 
coming under No. 3 are reported among the successful operations. 
Dr. Simon's analysis should therefore claim the undivided attention 
of the profession. Moreover, as most of the operations were per- 
formed at a recent date and by eminent surgeons, good diagnosis, 
scientific performance of the operation, and skillful after-treatment, 
were commonly secured. 

Results : Of 61 patients operated upon, 44 died immediately after 
the operation, or 12-^- per cent. In 5 patients the operation was of 
transient or no benefit at all, and only 12 were radically cured, or 
19f f per cent. These results are by far less favorable than those of 
former statistics, and, from a comparison, ovariotomy is more dan- 
gerous than the Caesarian section, because only 63 per cent, died in 
consequence of the latter, according to Dr. Kaiser's statistics, or 



173 

about § per cent., according to some other authors. (See Naegele's 
Oeburtsk. B. 2.) 

Dr. Lacroix reports the case of a woman who was affected with an 
ovarian cyst of the left side for two years, and the tumor had re- 
mained stationary during this time, being of the size of a child's 
head. When this woman became pregnant, the. cyst began to de- 
velop considerably. At the full term regular pains set in, but labor 
did not advance. Therefore, the attending physician punctured the 
enormously distended abdomen, and drew 16£ litres of an albumin- 
ous fluid, and ten hours afterwards the woman was delivered in the 
natural way. Two months after this, Boinet's iodine solution (Tinct. 
jardi 150 grm. kal. hydrojod. 4 grm. aqu. destill. 150 grm.), was in- 
jected. After the injection was made, the orfice of the canula was 
closed for ten minutes. But when the opening of the canula was un- 
corked, in order to let the iodine escape, not one drop of the solution 
came away, though every effort was made for this purpose. Not- 
withstanding the inflammation following was very trifling, and dis- 
appeared after the sixth day. Three months after the injection, the 
patient was discharged perfectly cured. 

In a case of ovarian dropsy, treated by Dr. Hutchinson, in the Me- 
tropolitan Free Hospital, a concentrated solution of iodine was em- 
ployed, and allowed to remain in. The injection was practiced twice, 
with an interval of about a month, and on each occasion after the 
cyst had been as completely drained as possible, a scruple of iodine, 
and half a drachm of iodide of potassium, dissolved in an ounce of 
water, constituted the injection, and was wholly retained. The rea- 
sons which induced Mr. Hutchinson to employ so concentrated a solu- 
tion, were, first, the belief, that, what was wanted to prevent re-secre- 
tion, was destruction of the epithelial lining membrane of the cyst 
by iodic cauterization, and that the stronger the fluid, the more cer- 
tainly would this be effected. Secondly, the hope that so concentrated 
a solution would be less likely to be absorbed quickly, and might 
therefore be left in, to produce its full effect with greater safety. 
Thirdly, the consideration that it is almost impossible to empty an 
ovarian cyst entirely by the trocar, and that, therefore, a dilute solu- 
tion is yet further reduced by mixture with the remaining fluid! 
Fourthly, that it is not desirable to introduce so much alcohol into 
the system, as is contained in from half a pint to a pint of tincture. 
With regard to the results it may be stated that, although four months 
have elapsed since the last .injection, the patient remains quite well, 
a tendency to refilling being manifested. 

A case of ovarian dropsy is reported from the practice of Dr. Bick- 
ermann, where eight ounces of the tincture were injected and retained, 
but with no success. 

Two cases are reported by Dr. Brower, in which Dr. T. B. Brown's 
method of compression after tapping were resorted to. After the cyst 
has been emptied by a large trocar, compresses of lint are so arranged, 
as to present a convex surface, and adapted as nicely as possible, to 
the concavity of the pelvis ; over these, straps of adhesive plaster 
should be applied, so as to embrace the spine, meeting and crossing 
in front, and be extended from the vertebral articulation of the eighth 



174 

rib to the sacrum. Over this strapping, a broad flannel roller, or a 
band with strings and loops, which tie or lace in front, may be ap- 
plied. 

The first case treated in this way by Dr. Brower, was that of a 
unilocular cyst, in which ten pints of clear fluid had been drawn off 
by the trocar. It resulted in a radical cure of the ovarian disease, 
and restoration of general health, six months having elapsed with- 
out any appearance of a return of the disease. In 1845, the same 
operation was practiced opon a similar case, in which two distinct 
cysts occupied the right hypochondriac region. In the course of the 
first forty-eight hours, severe peritonitis set in, which was promptly 
subdued, and the case progressed to a final and radical cure. [The 
writer is of opinion that the last mentioned case cannot be counted 
at all. We do not know whether it was the pressure or the perito- 
nitis, that effected the cure. — E. N.] 

Dr. McDaniel reports a case where a woman was tapped for ova- 
rian dropsy, 219 times, from 1841 to 1858. In this space of time 495 
gallons of water were evacuated. 

A case of death after paracentesis of an ovarian cyst has lately oc- 
curred at St. Thomas's Hospital. The operation was performed by 
Mr. Woakes, and about a pailful of thick fluid removed. The tumor 
was reduced in size, but a considerable bulk still remained. The wo- 
man gradually sank afterwards, and died exhausted on the fifth day. 

As it often happens that hydrops ovarii and ascites are mistaken 
one for another ; it is of importance to have an unfailing diagnosti- 
cal symptom. This is presented by the percussions of the lateral 
lumbar regions. If in a case of ascites, the patient is brought in a 
sitting posture, the percussion in the lumbar regions offers an equal 
(generally dull) sound on both sides. In case of ovarian dropsy 
one side is found dull, and the opposite resonant. This is explained 
by the fact that in hydrops ovarii, the intestines are driven towards 
the healthy side. In this way we are also able to decide, which of 
the two ovaries is diseased. 



Y. PATHOLOGY AND THERAPEUTICS OF 

UTERINE DISEASE. 

I. GENERAL DIAGNOSIS AND PATHOLOGY. 

1. Beitr'dge zur Geburtskunde und Gynaekologie. Von Dr. F. W. von 
Scanzoni. III. Band. (Mit 10 lithographirten Tafeln). Wiirzburg, 
1858. 

— Contributions to Midwifery and Diseases of Women. By F. W. von 
Scanzoni, M.D. 3d Vol. (With 10 lithographs). WUrzburg, 1858. 
(The single articles contained in this volume have been distribut- 
ed among the respective heads.) 

2. Histoire philosophique et midical de lafemme, consider 'dedans dans toutes 
les epoques principales de la vie avec ses diver ses functions, avec les change- 



175 

ment qui surviennent dans son physique et son moral, avec Vhygiene 
applicable a son sexe et toutes les maladies qui peuvent Pattendre aux 
different ages. Par Dr. Menville de Panson. Tom. I — III. Paris, 
J. B. Bailliere. 8vo. 1858. 

— A Philosophical and Medical History of Woman, etc. By Menville. 
de Panson, M.D. Paris J. B. Bailliere. 3 Vols. 8vo. 

3. Rosier, Dissertation sur les prineipales affections de la matrice. Paris, 
1858. 8vo. pp. 47. 

— Rosier, Thesis on the Principal affection of the Womb. Paris, 1858. 
8vo. pp. 47. 

4. Cartwright, Sam'l A., Practical Remarks on Epigenesis and Sterility. 
— New Orleans Jour. XV. 4. 

5. A Treatise on the Employment of the Speculum in the Diagnosis and 
Treatment of Uterine Disease, with three hundred Cases. By Robert 
Lee, M.D. London, John Churchill. 8vo. pp. 132. 1858. 

6. Burgess, Vaginal Stethoscope. — Jour, de Bord. April. 

t. McRuer, D., of Bangor, Me., an Inquiry into the Merits of Modern 
Doctrines, regarding the Frequency, Importance, Pathology, and Treat- 
ment of Abrasions, Excoriations, and Ulcerations, of the Os and Cervix 
Uteri. — Maine Med. Report. I. 4 and 5. 

8. Clos, J. A. on the Influence of the Moon upon Menstruation. — Jour, 
de Toul. May. • 

9. Marable, J. T., of Memphis, Tenn., on Cases of Early Catamenia. — 
Memphis Recorder. February. 

10. Scarburgh, G. T., on a peculiar Case of Retention of the Menstrua 
from Occlusion of the Os Uteri. — Virginia Med. Jour. XI. 3. Sept. 

11. Farre, on a periodical Neuralgia of the Womb and its Appendages; 
Daily and Annual Periodicity. — Gaz. de Lyon. June. 

12. Becquerel, on Neuralgia of the Uterus. — Gaz. des Hop. 47. 

13. Banks, J. T., on Partial Elach or Blue Coloration of the Skin. — 
Dubl. Quart. Jour., May. 

14. Busquet and Gestin, on Partial Coloration of the Skin (Chrom- 
hidrosis). — Gaz. des Hop. 109. 

15. Coote, Ch., on Infra-Mammary Pain. — Med. Tim. and Gaz. 421. 
July 24. 

16. Plaskitt, J., Treatment of Infra-Mammary Pain, by Electricity. — 
Med. Tim. and Gaz. 433. Oct. 13. 

17. Schlager, on the Influence of Menstruation and its Anomalies upon 
the Development and Progress of Mental Derangement. — Allg. Zeit- 
schrift fur Psych., von Damerow. B. XV. 4 and 5. 

18. Traite de la Follie des Femmes enceintes, des nouvelles accouchees et 
des nourriees, et considerations medic. -legates qui se rattachant a 
ce sujet. Par Dr. L. V. Marce\ In 8vo. Paris, 1858. 

— A Treatise on Insanity of Pregnant Women, etc. By L. V. Marcd, 
M.D., etc. 

19. Brosius, on Uterine Congestion and Mental Derangement. — Central 
Zeitung, 27. 



176 

20. Becueil desfaits pour servir a Vhistoire des ovaires et des affections 
hysteriques de la femme. Par Dr. Ndgrier. Angers : Cosnier et 
Lacheze. In 8w. pp. 116. 1858. 

— Analysis of Facts connected with the History of the Ovaries and 
Hysterical Affections. By Ndgrier, M.D., etc. 

21. Pidoux, Bronchitis with Laryn'gospasmus and Aphonia, Several 
Paralyses and Neuralgias in a Hysterical Woman; Disappearance of 
all these Symptoms during a Typhus Fever, and their Reappearance 
after Recovery from the Fever. — L'Union 11, 14, 15. 

22. Drewry, on Pathology of Hysteria. — Atlanta Jour., Jan. 

23. Briquet, On Anesthesia in Hysterical Women. — L'Union 87, etc. 

24. Nonat, a Case of Hysteria and Symptomatic Retention of Urine, in 
Consequence of Endometritis and Perimetritis. — Gaz. des Hop. 31. 

25. Althaus, T., On Hysterical Aphonia. — Med. Tim. and Gaz. 433. 
Oct. B. 

26. Aran, F. A., General Remarks on the Treatment of Uterine Disease. 
—Bull, de Thdr. April 30.— New York Jour. VI. 1. January, 
1859. 

2T. Storer, H. R, Cupping the Interior of the Uterus. — The Amer. 
Jour. Oct. 

28. Trend, H. G., Abortion produced by Arsenic. — Brit. Med. Jour. 

29. Broca, Fatal Peritonitis after Application of the Actual Cautery to 
the Uterine Neck.— Monit. des Hop. VI. 129. Oct. 30. 

30. Scanzoni, on a Case of Death occuring after Injection of Carbonic 
Acid into the Cavity of the Womb. — Beitr. zur Geburtsh. B. 3. 
p. 181.— New York Jour. V. 2. Septemb. 

31. Mackenzie, P.. W., on the Action of Galvanism on the Contractile 
Tissue of the Gravid Uterus, and on its Employment in Obstetrical 
Practice. — Lancet. March. 

32. Warren, Occlusion of the Uterus — Rupture of the Left Fallopian 
Tube. — Boston Jour. July. 

33. Blair, on Vicarious Menstruation. — Oglethorpe Jour. April. 

34. Kirsten, T., on the Education of Midwifes in Saxony. — Monat- 
schrift f. Geburtsk. XII. 3. Sept. 

35. Churchill, P., on Obstetric Morality. — Dublin Quart Jour. L. 1. 
August. 

Dr. Lee is the representative of a certain clique in England, and 
his treatise on the employment of the speculum will meet with a 
favorable reception among his adherents. From this point the work 
must be considered, it having no other value. Far from proving the 
necessity of restraining the use of the speculum, it reveals a deplor- 
able state of practical sense and medical education among English 
practitioners. Nothing could have done more harm to the reputa- 
tion of our brethren abroad than this little book. Every reader, who 
shall take the trouble to peruse it, must come to the same conclu- 
sion ; and even Dr. Lee's great example, as recorded in the prelimi- 
nary remarks, where a woman died eight days after an examination 



177 

with a speculum, from meningitis spinalis, proves nothing but the 
gross ignorance and barbarism of the attending physician. 

Dr. Burgess has modified the shape of the ordinary stethoscope, so 
as to make it somewhat larger, for the purpose of introducing it in- 
to the vagina. In this way he was enabled to judge of the foetal 
life in the third and even second months of pregnancy. In the cases 
examined, a sound was perceived similar to that called placentar 
souffle. 

After a very elaborate analysis of the points contested by our lead- 
ing men in uterine, pathology, and after fully exposing his views 
upon the subject. Dr. McRuer sums up in the following way : 

1. Ulceration is a lesion presenting an excavation or solution of 
continuity, produced by a molecular death, the lifeless elements 
being absorbed back into the circulation through the action of the 
absorbents, and it is generally the result of a constitutional cause ; 
while abrasions and excavations are produced either by mechanical 
or chemical agents, by the attrition of foreign bodies, or the escha- 
rotic effects of morbid secretions, usually the product of other parts, 
and coming in contact with the ulcerated surface. 

2. While abrasions or excavations are of frequent occurrence on 
the cervix uteri, especially in the pregnant female, ulceration rarely 
exists on that appendage, excepting from mechanical or specific 
causes, and all of these lesions, when not of a special character, are 
of themselves of trivial importance, only demanding by their com- 
plication with other more important diseases, the serious attention 
of the medical practitioner. 

3. The premonstrative use of the speculum, or the direct applica- 
tion of caustics, are seldom justifiable or required in the diagnosis 
or treatment of diseases of the cervix uteri, for tactile demonstration 
is more to be relied upon than specular examination, and the appli- 
cation of caustic agents for the cure of simple lesions, ought never 
-to be made destructive, but only to produce a modification of the 
molecular action of the parts diseased. 

4. As abrasions, excavations, and ulcerations are in a great ma- 
jority of cases, the result of constitutional disease, or functional de- 
rangement, therefore the treatment of these lesions must be prin- 
cipally directed to the general vitiation, or the physiological disturb- 
ance ; and to pronounce the local affection a disease per se, is to 
encourage a practice, which, while it does not remove the organic 
evil, subjects the patients to a greater injury by doing violence to 
their moral sensibilities. 

Dr. Marable reports four cases of early catamenia in negro girls 
from seven to eleven years of age, and suggests the inquiry, whether 
they arise from a recurrence to the original constitutional type of 
of the race, or whether these cases are idiosyncrasies. 

Dr. Scarburgh's case reads as follows : Mrs. H. E., a negro wo- 
man, suffered from occlusion of the os since her last unusually pain- 
ful labor. On examination, a large, pear-shaped tumor was found 
extending from the symphysis as far up as above the umbilicus. 
Through the speculum the os appeared to be entirely closed by a 
false membrane. With a straight bistoury an attempt was made to 
12 



178 

cut through the occluding membrane, but so dense and fibrous was 
it, that the effort was abandoned. Recourse was next had to a sharp 
trocar. This, too, after many unsuccessful efforts, was also abandoned. 
From the external toughness of the membrane, it was deemed use- 
less to attempt to cut through it, and no further effort was made. 
The patient died soon afterwards from exhaustion. 

Autopsy. — The abdominal tumor was soft and fluctuating in its 
lower two-thirds. The abdominal walls were closely adherent to 
the tumor, requiring nice dissection to separate them ; so were tho 
intestines. The neck of the uterus was with great difficulty cut 
through, and on "entering the cavity, about a quart of muco-purulent 
fluid escaped, and lying in it was an oblong ball of coarse, matted 
hair, about four inches long, and two and a half inches in diameter. 
Attached to the walls of the cavity were found several smaller pieces 
of hair. The whole fundus uteri seemed to have been converted 
into a large cyst, which, upon being opened, was found to contain 
steatomatous matter, with numerous bands and some few bloodves- 
sels traversing it in several directions. Dr. S. is of opinion that the 
hair was used as a tampon to stop a post-partum hemorrhage. 

In the case reported by Dr. Farre, the attacks of neuralgia ap- 
peared at about the same time in three successive years, and were 
at last successfully treated by valerianate of quinine. 

In opposition to many physicians, who consider uterine neuralgia 
rather as a symptom, connected with pathological conditions of this 
organ, Dr. Bequerel believes it to be an idiopathical disease, not un- 
frequently met with. Its manifestations are intense, violent, lancin- 
ating, and intermittent pains, the seat of which is in most cases the 
uterus itself, from whence they are spreading at times to the lumbar 
region, hypogastrium, perineum, and fundament. The pain is gener- 
ally increased by the touch. Continued and quick walking, as well 
as cohabition, are apt to increase the suffering. Very often the 
entire nervous system shows an increased sensibility, owing to the* 
diseased state of the womb. The author distinguishes a symp- 
tomatic, a utero-lumbar neuralgia, and a neurosis of the uterus. 

The course of the disease is always of a chronic character, and 
mostly intermittent ; the duration of symptomatic neuralgia always 
depends upon the primitive affection. The diagnosis must be de- 
rived from digital and from specular examination; in this way mate- 
rial changes may be easily recognized ; the neurosis must be diagnos- 
ticated by way of exclusion, its presence may be stated from the 
absence of organic disease and painful irradiations, the presence of 
the latter indicating an utero-lumbar neurosis. In regard to prog- 
nosis, it may be said that the disease is very difficult to remove, 
in exhausted anaemic subjects. 

The treatment of symptomatic neuralgia has to be directed against 
the primative disease ; besides this, the neuralgia itself must be 
treated with the different narcotics ; of great value, are the use of 
full baths, and in cases with a manifest intermittent character, the 
sulphate of quinine can be recommended. The method of Cruveil- 
hier, who applies a mixture of linseed meal to the cervix uteri, is 
not praised by the author. He tries to apply the remedies to the 



179 

cervical canal, or to the cavity of the womb itself, by introducing 
small conical rollers formed of castor oil, gum-arabic, and tannin, 
into the womb j after ten or twelve hours they are melted down, 
thus leaving the tannin to act upon the mucous membrane. This 
has to be repeated every third or fourth day. The author has ap- 
plied in the same way opium, belladonna, etc., with great benefit, 
thus lulling in a short time the most violent pains. Other impor- 
tant remedies are cold water-cures, the baths of St. Sauver, Ems, 
and sea-bathing. 

From Dr. Banks' article we give the following abstract: Dr. Leroy 
de Mericourt first of all, described a peculiar coloration of the skin, 
which he encountered in several women at Brest. A case belonging 
to this class of diseases, has been already published by Dr. James 
Yonge in the "Philosophical Transactions" of 1109. A similar case is 
reported by Dr. Billard, in 1831, who called it " cyanopathie cutande." 
In all these instances the abnormal color was observed in young 
women from sixteen to twenty-two years of age. Out of ten cases, 
where the condition of menstruation is recorded, dysmenorrhoea or 
amenorrhcea, had preceded the morbid condition of the skin. This 
coloration ranges between the black of Chinese ink and a deep blue. 
In those cases observed by Banks, the place affected looked as if 
painted with Berlin-blue. It is rarely confined to the eyelids alone, but 
spreads over the cheeks, the lateral portions of the nose and fore- 
head. In Billard's case the coloration extended over the neck, chest, 
and abdomen. It is very remarkable, that in most instances pieces 
of linen, which cover the affected portions, are dyed with the blue 
color. In almost every case known disturbances in the menstru- 
ation had existed. Mental emotions, over-exercise, increased tem- 
perature have a tendency to increase the intensity of the color. Mar- 
riage # and pregnancy seemed to have no influence with some of the 
patients ; in one case, nursing seemed to modify the affection favor- 
ably. The shortest duration of the disease was three months ; in 
one of Leroy's cases the disease lasted for seven years. Some of 
the cases were connected with hematemesis, hemoptae, and other dis- 
tressing symptoms. Banks' patient had been insane already two 
years, before the blue coloration of the eye-lids made its appearance. 
The nature of the affection is unknown up to the present time. Bil- 
lard considers a modification of the transpiration from the skin 
as the source of the disease, while Neligar believes that the color- 
ing matter is formed in the sebaceous glands, and hence he called it 
stearrhoea nigricans. Law called it blepharomelsena and Leroy, 
blepharomelanosis. 

Dr. Bousquet's article contains a historical sketch of the disease 
called chromhidrosis, with an addition of some new observations. 
The cases known up to the present time, are to the number of 
twenty-two : viz., Dr. Younge, of Portsmouth, one ; Dr. Billard, of 
Corzd, one ; Dr. Teewan, of London, one ; Dr. Bousquet, of Mont- 
oulier, one ; Dr. Neligan, of Dublin, one ; Dr. Law, of Dublin, one ; 
Dr. Banks, of Dublin, one ; Dr. Leroy de Mericourt, of Brest, thirteen 

Dr. Coate read a paper before the Harveian Society of London, on 
infra-mammary pain. Having discussed in detail each of the 



180 

characters of the pain, he examined briefly the most popular hypoth- 
eses, which had been devised to account for it. A very plausible 
hypothesis connects this pain with uterine or ovarian disorder. The 
pain is certainly of rare occurrence in the male ; but the author 
thought he had noticed two unambiguous cases of it, within the last 
eighteen months. Assuming for argument's sake, that it was limited 
to females, he proceeded to inquire, whether in them it was depend- 
ent upon uterine disorder ; with, rgspect to age, he found that the 
period of uterine activity was the favorite, but not the exclusive 
epoch of the pain. Overlactation and excessive child-bearing were 
recognized in a few instances only. Four women (out of fifty cases 
analyzed) were sterile ; seven had a liability to abortion. The 
menstrual function was physiologically absent in twenty of the re- 
maining thirty ; it was perfectly normal in eleven ; regular but 
scanty in seven ; regular but profuse in four ; irregular or absent in 
eight. Leucorrhcea was acknowledged in ten cases only ; in six of 
which, uterine disease existed. These facts appeared conclusive 
against the hypothesis. That uterine disorder frequently accom- 
panied mammary pain was certain ; that it should be the cause of it 
was impossible. The next hypothesis, that of spinal irritation, was 
wholly unproved. The next hypothesis, that of Ollivier, and of 
Brown, of Glasgow, was, that the pain was the result of pressure 
upon the roots of spinal nerves, from a congestion of the intra-verte- 
bral plexus of veins, or from a. transient curvature of the spine, oc- 
casioned by disproportionate fatigue of some one set of spinal 
muscles. Another explanation, also based upon the idea of pressure, 
had been propounded by Henle, which accounts in some measure for the 
localization of the pain. The anatomical character by which the left 
infra-mammary region was distinguished, was the peculiarity of its 
venous circulation ; the effect of which was, that if any obstruction 
existed to the return of the venous blood by the azygos vein, the "brunt 
of the pressure would fall upon the intermediate intercostal spaces of 
the left side. Henle thought that such pressure, acting upon the peri- 
pheral extremities of the intercostal nerves, might occasion the pain, 
and he suggested that the first impulse to disturbance of the circula- 
tion might be given by uterine or ovarian congestion. Dr. Coates' 
own explanation of the phenomenon in question, was given as fol- 
lows : The constitutional character of the patients was well marked ; 
being universally that of defective nutrition. Twenty-one were 
anaemic. The concurrent diseases were phthisis, secondary syphilis, 
and diabetes mellitus. The functional derangements accompanying 
infra-mammary pain, were disorders of the vasomotory system of 
nerves, and of other nervous departments. Paralysis of the motor 
nerves had, as its immediate physical result, exalted temperature 
and local congestions. Hence, he inferred, that infra-mammary pain 
was a symptom of a generally depressed state of nervous power, and 
a symptom of vasomotory derangement. The conclusions drawn, 
were as follows : supra-mammary pain was a peripherical neuralgia, 
having its probable origin in mal-nutrition of the nerves of the part. 
This again resulted from disordered circulation, affecting the left in- 
fra-mammary region especially, by reason of its peculiar anatomical 



181 

relations, as exposed by Henle. The immediate cause of this vascu- 
lar derangement, consisted in disordered enervation of the smaller 
arteries of the whole body ; a condition which, while in the infra- 
mammary region, it occasioned neuralgia, in other parts gave rise to 
chills and flushes, to palpitation, to disturbed secretion, haemorhages, 
and flushes. The female was far more liable to all these derange- 
ments than the male. Therefore, the indications for treatment, were 
to stimulate the vasomotory nerves into temporary activity, so as to 
relieve special symptoms ; secondly, to give them permanent vigor, 
by improving the general nutrition, by electricity, counter-irritation, 
good food, air, rest, and tonic medicines. Topical applications to the 
uterus and vagina had produced no effect upon the pains. 

Dr. Plaskitt reports that two patients, suffering from inter-mam- 
mary pain, were partially and temporarily relieved by wearing 
Pulvermacher's chains, while one was relieved by electricity. 

Dr. Schlager, in his treatise on the influence of menstration upon 
mental derangement, comes to the following conclusions, drawn 
from a considerable number of observations. In a large number of 
cases, the commencement of normal menstration, exercises no influ- 
ence upon the existing disturbance of mind, especially so in cases of 
hyperphrenia and aphrenia. But whenever an influence was mani- 
fested, it was that of increased cerebral and sexual excitement, even 
in those cases where the latter was absent at any other time. Some 
irregularities in the monthly courses, occasioned the development of 
psychical derangements, or modified their course. The primitive 
menostasia effected congestions of the brain with consecutive mental 
affections, or convulsions, which ceased with the show. The conse- 
cutive menostasies take a considerable share in the development of 
mania pro graviditate. The cessation of menses from pregnancy, 
provoked in, many instances a mental derangement, which disap- 
peared after delivery and reappparance of the flux. Of considerable 
importance is the sudden suppression, which is generally followed 
by acute mania, chorea, catalepsy, or a relapse of those who had re- 
covered their senses. Epistaxis seemed to afford a great relief in 
cases of imminent menostasia. The so-called imperfect menstruation 
has been often observed in women stricken with alienation of mind, 
and mostly in melancholia. Painful congestive and nervous men- 
struation were often observed. Premature involution promoted 
rapidly the primary mental affection into the consecutive form, under 
the symptoms of vehement cerebral congestion. In cases of this 
kind, the prognosis is very unfavorable. Diseases of mind originat- 
ing at the normal change of life, are generally characterized as 
melancholia. In some cases, the disease already existing, changed 
very rapidly to aphrenia. Profuse menstruation was found in 
patients suffering from hyperphrenia and aphrenia. 

Dr. Aran, in his article on treatment of uterine disease, remarks 
that both local and general treatment for curing diseases of the 
womb are of equal importance, and every single case has to be 
treated individually. The different abnormal conditions of the womb, 
as detected by examination, do not always demand medical treat- 
ment, but only in those instances where they really disturb the 



182 

health and comfort of the patient they have to be removed. as far as 
possible. In most cases we must be satisfied with a palliative 
treatment, because it is very rarely desirable, or within the limits of 
our art, to push treatment so far as to reduce the womb to its natu- 
ral condition. All that is required for a perfect cure consists in a 
lasting and entire removal of the functional disturbances. 

The principal therapeutical indications to be attended to, in the 
greatest number of uterine disease^, may be comprised as follows : 
congestion, pains, profuse secretions, hypertrophy, and alterations in 
the position of the womb. 

As the congestion has its chief source in the monthly afflux of 
blood to the womb, we have first, to diminish the state of congestion 
during the catamenia, and second, to remove the state of congestion 
that remains after every period up to the next time. To diminish 
congestion during the menstrual term, Dr. Aran recommends the 
application of leeches, and cautions against the rule of hydrotherap- 
ists who use cold-water baths, because he has seem alarming symp- 
toms following their application. 

The state of congestion after menstruation may be active or 
passive. In the former instance local antiphlogistics are to be used, 
while revulsive remedies (cold, external irritantia) are to be applied 
in passive congestion, depending upon a general or local state of 
atony. 

The pain often depends on congestion or other lesions, and dis- 
appears upon the removal of the causes. In other instances, we are 
unable to find out the causes of pain, or it is so predominant, that we 
have to direct our remedies against this symptom alone. If the pain 
is more of a spasmodic character (coliques-ute'rines), the castoreum, 
camphor, and the different preparations of ammonia are generally 
prescribed successfully. But more often we are called to combat 
hypersesthesia and neuralgia, and Dr. Aran highly recommends the 
local application of opium to the neck of the womb. He believes 
that he has rendered a great service to the profession by this advice, 
because it is free from evil consequences, such as nausea, constipa- 
tion, etc., circumstances always following its general administration. 
[The writer's experience is opposed to Dr. Aran's proposition. I 
have often applied opium to the neck and to the inner surface of the 
womb. If it was given in a sufficiently large dose to soothe uterine 
pain, its influence upon the system seldom failed to manifest itself. 
In the case of a lady to whom I applied it lately, it gave rise to 
alarming symptoms, as violent vomiting, and speaking as if in a 
trance, for many hours. — E. N.] Other remedies, but with a much 
more transient effect, are cold, chloroform, and carbonic acid gas. 

Profuse secretions have to be attended to especially, because their 
presence alone is often sufficient to produce irritation and ulceration 
of the tissues with which they are in contact. Therefore, injections 
are of great value, be it of water alone or of medicated solutions. 
Besides injections, the application of revulsive remedies, such as 
vapor baths, and more especially strong purgative injections, are of 
the greatest value. 

Against the hypertrophy a local and general resolutive treatment 



183 

has to be resorted to. The latter comprises the cutaneous and in- 
testinal revulsives, and the internal administration of alteratives, 
such as mercury, iodine, arsenic, etc. These remedies are not only 
to be applied till the uterus is reduced to its natural size, but till the 
functional disturbances arising from hypertrophy are removed. 

The displacements of the womb ought to be attended to as soon as 
they begin to disturb the patient's health. For this purpose the 
womb has to be replaced and maintained in its right position. In 
very many cases it is sufficient to unload the intestinal tube in order 
to prevent its pressure upon the uterus. Besides attending to falling 
of the womb itself, we have to treat the functional derangements of 
the neighboring organs. Above all, constipation is a most common 
coincidence with uterine disease. The best way of regulating the 
activity of the alimentary canal, is by the use of plain or medicated 
injections once or twice a day. 

Dysuria, in uterine affections, is very often owing to an abnormal 
state of the urine itself, being overloaded with urea, or uric acid. If 
this is the case, the alkaline mineral waters are of the greatest use. 
The best way to regulate the disturbed functions of the stomach is a 
proper diet. Dr. Aran recommends roast meat above all, hydro- 
therapy, mineral waters, and sea-bathing. While hydrotherapy may 
be used at every stage of the disease, the use of mineral waters, and 
sea-bathing must be dispensed with until the first and gravest local 
symptoms are removed. [Altogether, Dr. Aran's notions of the 
therapeutical value of mineral waters are unsettled. He thinks that 
there is no difference in recommending a sulphureted, or a merely 
alkaline water, provided one is recommended. The application of 
waters containing iron is proposed as something new, while Dr. 
Aran ought to know, that they were in use in Germany for the cure 
of uterine disease half a century ago. — E. N.] 

It often happens, at the close of treatment, that while the local 
lesions seem to be removed, the patient is troubled with violent 
pains. These pains, after some time, disappear spontaneously, and 
it would be wrong to subdue them by another energetic medication. 
This is the time when the patients are sent to the country or sea- 
shore with the greatest benefit. 

The treatment of uterine disease has to be continued for a great 
length of time before the physician can be satisfied that the good 
effects obtained will be lasting, and the disease, if not cured entirely, 
will not fail to return soon and severely. 

Dr. Storer describes an instrument for cupping the interior of the 
uterus. It consists of an air-pump, with a perforated tube, which is 
introduced into the cavity of the womb. Two cases of amenorrhoea 
are reported, where the instrument was successfully applied. 

The carbonic acid gas has been applied of late as a local means 
more frequently, and Dr. Scanzoni himself has proposed its use for 
inducing premature confinement. The following case, therefore, is 
of no little interest, and will caution practitioners in the use of a 
remedy which hitherto has been considered void of danger, when 
locally applied. Dr. S. was called in consultation to see a lady who 
suffered from an enormous hypertrophy, with prolapsus of the cervix 



184 

uteri. He therefore recommended the removal of the dise'ased por- 
tions by an operation. The attending physician fully agreed with 
this proposition, but thought it a good plan to apply a remedy which, 
in his opinion, had an influence upon the contraction of the vascular 
system, in order to lessen the chances of excessive hemorrhage, after 
the amputation of the cervix. He therefore proposed to introduce 
the carbonic gas into the cervix uteri for several days. Dr. Scan- 
zoni, though not believing that this remedy would have any con- 
siderable influence upon the quantity of blood to be lost after the 
operation, consented to its application, more out of regard to the at- 
tending physician. A dried pig's bladder, to which a canula was 
attached, was filled with the gas, and the mouthpiece introduced 
into the gaping orifice, and the bladder gently pressed. But scarcely 
two or three cubic inches had entered the cervix when the patient 
screamed out, saying, "I feel air entering my stomach, head, 
throat." These, her last words, were followed immediately by a 
violent, general tetanus, respiration became very difficult and rat- 
tling, the pulse weak and frequent, and notwithstanding everything 
was done by several physicians present, to save her life, she died If 
hours after the application of the gas. 

The post-mortem, two days after death, revealed no pathological 
condition whatever, besides a far advanced oedema of the lungs. 
But a pregnancy of four months was discovered, which was not 
detected during life, on account of certain peculiarities of the uterus, 
for the walls of the uterus were not much thicker than a piece of 
card paper, so that it looked at first like a large cyst, filled with 
water. The hypertrophy generally connected with pregnancy, seemed 
to be restricted to the uterine neck in this instance, and the distance 
between the external and internal orifice of the womb measured 3£ 
inqhes. The ovum was found in a perfect condition. No traces of 
peritonitis were found, and Dr. Scanzoni is of opinion, that the gas 
must have entered one of the larger uterine vessels. 

After a number of experiments and observations, Dr. MacKenzie 
comes to the following conclusions : 1. A sustained current of elec- 
tricity, directed longitudinally through the uterus from the upper 
portion of the spinal cord, exercises a remarkable influence in in- 
creasing the tonicity and contractility of the uterine fibre. 2. In 
such increased tonicity or contractility of the uterine fibre, so excit- 
ed and sustained, we have a powerful and reliable means of moder- 
ating and controlling uterine hemorrhage, and of simultaneously 
accelerating the dilatation of the os uteri, and the general progress 
of labor. 3. Such sustained current of electricity may be continued 
for a lengthened period, when the object to be attained requires it, 
without any appreciable pain or inconvenience to the mother, or 
danger to the child. 

Dr. Warren's patient had a. very severe confinement about four 
years ago, and had never menstruated since. On examination, a 
large prominent tumor was found in the abdomen, and not the slight- 
est trace of the os uteri in the vagina. Soon after the vaginal ex- 
amination was over a bloody or tarry discharge commenced to flow 
from the genitals, being accompanied by forcing uterine pains, and 



185 

with a great diminution of the abdominal swelling, which, however, 
was confined only to the right lobe of the abdominal tumor, while 
the left portion of the swelling remained unchanged. The following 
day suddenly she was seized with a violent pain in the abdomen, 
and she died in about two days. The post-mortem examination 
showed that the right lobe of the tumor had been formed by the 
uterus, which had emptied itself through the vagina. The left lobe 
consisted of the left Fallopian tube enormously distended into a very 
delicate sac by the retained menstrual fluid. There was no commu- 
nication between the Fallopian tube and the uterus, and the tube 
had ruptured and discharged its contents into the abdominal cavity, 
causing death. 

The subject of Dr. Blair's observation was a young lady of fifteen 
years, who never menstruated, but at each period had all the evi- 
dences of approaching menstruation, which would suddenly disap- 
pear, and she would be attacked with accute inflammation in the 
right eye. By appropriate treatment the patient began to menstru- 
ate freely, and was entirely restored. 

Dr. Churchill's article is an able defense of the operation of cra- 
niotomy, if the child be alive, in those cases where it is physically 
impossible, that a living child can be delivered per vias naturales. 
We fully sustain Dr. Churchill in defending the practice of des- 
troying a child, which by no means can be born alive. We 
always acted on the same principle, and shall continue to do 
so. The few opponents of this practice, hold that craniotomy is 
just as dangerous for the life of the mother as Caesarian operation, 
basing their assertions on the statistics in their reach. In order to 
put the respective statistics on a fair footing, the circumstances un- 
der which the operations were executed, ought to be taken into con- 
sideration. Most of the number of- Caesarian operations recorded in 
our annals have been performed under comparatively favorable cir- 
cumstances, i. e. when the patient's strength was not impaired by 
previous protracted labor. If an equal number of early craniotomies 
would be compared with Caesarian operations performed under the 
same circumstances, the result would be quite different, i. e. the ave- 
rage of fatal cases would be hardly more than one per cent, for crani- 
otomy. But all this is theoretical reasoning and has only indirect 
bearing upon every day practice. Let the sister or the wife of our 
opponents be placed in the dilemma of craniotomy or Caesarian ope- 
ration, and all their sophistical reasoning will melt away like snow, 
before the warming rays of a feeling heart. — E. N. 



2. RETARDED DEVELOPMENT, MALFORMATIONS AND DIS- 
PLACEMENTS. 

1 . Krieger, on Atresia Ani and Uterus Bicornis. — Monatschr. f. Geb. 
XII. 3. 

2. Picard, Retention of Menses. Owing to Imperforated Os Uteri; 
Operation; Recovery. — Gaz. des Hop. 64. 



186 

3. Caillat, Imperforated Hymen. — Gaz. des Hop. It. 

4. Tuppert, Case of Atresia Uteri Congenita. Scanzoni's Beitr. z. 
Geburtsk. B. 3. 

5. Hoist, Pregnancy with Bilocular Uterus. Scanzoni's Beitr. z. 
Geburtsk. B. 3. 

6. Van Holsbeck, Amenorrhea, owing to Imperforated Hymen. — Presse 
radd. It. 

t. Patin, G., Atresia Vagince; Operation during Labor. — Med. Ztg., 
Russl. 24. 

8. Coates, Ch., Total Absence of Vagina. — Lancet, II. July. 

9. Sorbets, L., Anteversion of the Womb during Delivery and Early 
Rupture of the Membranes. — Gaz. des Hop. tl. 

10. Betz, F., Incarceration of an Anteverted Pregnant Uterus. — Memor. 
a. d. Praxis. III. 2. 

11. Bonnet, A., Du soulevement et de la cauterization prqfonde du cul- 
de-sac retro-uterih dans les retroversions de la matrice. Lyon, Ving- 
trinier. 8vo. pp. 30. 

— Bonnet, on Replacement and Deep Cauterization of the Retro- Uterine 
Cul-de-Sac in Cases of Retroverted Uterus, etc. 

12. Villeneuve, on Constipation as a Cause of Retroversion of the Womb 
during Pregnancy. — Journ. de Bord. April. 

13. Chapplain, on Retroversion of the Pregnant Uterus. — Gaz. des 
Hop. 5t. 

14. Sims, M., a New Uterine Elevator. — Americ. Jour. LXIX. 
January. 

15. White, on a Case of Obliquity of the Uterus during Labor. 
(Kead before the Buffalo Med. Assoc.) — Buffalo Jour. IV. Vol. 
XIV. Sept, 

16. Hoist, F., on the Treatment of Flexions of the Uterus. — Scanzoni's 
Beitr. z. Geburtsk. B. 3.— N. Y. Jour, of Med. V. 2. Sept. 

It. Castex, Complete Inversion of the Uterus, Replaced by the Arabian 
Method,— Gaz. med. de l'Algerie.— L'Union XII. 103. Aug. 31. 

18. Verity, F. S., Inversion of the Uterus Successfully Reduced. — 
Montreal Chronicle. Nov. — Americ. Jour. LXIX. January. 

19. Tyler Smith, W., on a Case of Complete Inversion of the Uterus 
of nearly Twelve Years' Duration, Successfully Treated. — Lancet. 
June.— N.Y. Jour, of Med. V. 2. Sept. 

20. White, J. P., of Buffalo, Report of a Case of Inversion of the Uterus, 
Successfully Reduced after Six Months, with Remarks on Reduction 
in Chronic Inversion. — Amer. Jour. July. 

21. Westmoreland, on Prolapsus of the Uterus. — Atlanta Jour. 
February. 

22. Jobert de Lamballe, Lectures on the Falling of the Womb. — 
L'Union XII. 95. Aug. 12. 

23. Mayer, C., Prolapsus of the Uterus Complicated with Hypertrophy 
of the Uterine Neck; Treatment. — Monatschr. f. Geburtsk. March. 
—N.Y. Jour, of Med. V. 1. July. 



187 

24. Huguier, on Hypertrophy of the Uterus and its Neck in Connection 
with Prolapsus Uteri; Amputation of the Collum Uteri. — Gaz. hebd. 
May, 14. 

25. Bonorden, on Prolapsus Uteri and its Treatment by Internal Bern- 
edies. — Pr. Ver.-Ztg. 2. 

26. Kunkler, on Treatment of Prolapsus Uteri. — Gazette des H6p. 
June, 15. 

2t. Steele, H., the Pessary and other Mechanical means in Prolapsus 
Uteri. — Oglethorpe Med. and Surg. Jour. June and Oct. 

28. Olivier, CI., The Pessaries in the Actual State of Science. — Gaz. 
des Hop, 91. Aug. 5. 

29. Noeggerath, E., Bemarlcs on the Employment of Pessaries with the 
Description of a New Instrument. ( With Illustrations). — New York 
Jour. V. 2. Sept. 

30. Mayer, A. Jr., on Uterine and Vaginal Prolapsus, its Treatment by 
Dr. Zwank's Instrument, and the Conditions which prevent its Ap- 
plication. — Monatschrift f. Geburtsk. July. — N. Y. Jour, of Med. 
VI. 2. March, 1859. 

31. Savage, H., Clinical Experience on the Nature and Treatment of 
Uterine Deviations, more especially of Prolapsus. — Med. Tim. and 
Gaz. 398. Feb. 13.— Lancet. June. 

32. Bendot, Ch. P., Essai sur. les moyens chir. employis pour la cure 
radicale du prolapsus de I'ute'rus et sur Vepisiorrhaphie enparticulier. 
These de Strasbourg. Impr. Silbermann. 8vo. pp. 55. 

— Bendot, on the Means employed for the Badical Cure of Prolapsus 
Uteri, more especially on Episiorrhaphy. Thesis. 

33. Toland, H. H., Procidentia Uteri. — Operation; Cure. — Pacific 
Med. and Surg. Jburn. I. 9. Sept. 

34. Vernon, H. H., Remarks upon M. Baker Brown's Operation for the 
Cure of Prolapsus and Procidentia Uteri. — Lancet. February. 

35. Brachet, on the Curative Effect of Pregnancy upon Betroversion 
and Prolapsus of the Uterus. — Gaz. de Lyon. Aug. 

36. Rigby, E., the Squatting Uterus. — Med. Tim. and Gaz. Jan. 30. 

37. Hecker, A Bemarkable Case of Betroversion Uteri in the Sixth 
Month of Pregnancy. — Mon.-Schr. f. Geburtsk. XII 4. Oct. 

38. Crosse, W. T., Pathological Appearances fourteen years after the 
Bemoval, by Ligature of an Inverted Uterus. — Med. Tim. and Gaz. 
413. May, 29. 

With regard to treatment of uterine displacements, we have re- 
ceived very encouraging reports from Prof. White of Buffalo, and 
Dr. Tyler Smith of London. Both of them were fortunate in the re- 
duction of an inverted uterus of long standing, and each by a some- 
what different proceeding. Further, we must call the attention of 
our readers to Dr. Mayer's and Huguier's articles on operative treat- 
ment of prolapsus uteri. The most important contribution to the 
doctrine of retarded development we have received by Dr. Krieger, 
of Berlin. 



188 

Dr. Krieger, after a synopsis of the embryological development of 
the urogenital system, proceeds to explain the coincidence of atresia 
ani and uterus bicornis, by the non-disappearance of the caualis uro- 
genital, and mentions' the not yet decided question of superfoeta- 
tion. A number of cases has been published, in which a second 
child was born a few weeks or months after the birth of a first child. 
These cases are very few in number, and in most of them no ana- 
tomical examination of the uterus was performed. Those in which 
the condition of the uterus had been satisfactorily explored, are the 
following : In a thesis written by Dr. Cassan (Recherches anatomiques 
et physiologiques sur lescas d? uterus double et de super/elation, Paris, 
1826V 41 cases of uterus duplex are mentioned. Among them, sev- 
eral instances of double fetation are reported ; and the post-mortem 
examination of a woman, 40 years of age, whose double uterus had 
the appearance of two inverted pears, which were united at their 
neck, with a common os uteri. This woman had given birth to 14 
children, none of which had been born at the full term. After hav- 
ing been delivered of twins of 4£ months' gestation with one pla- 
centa, she had another 6 weeks' foetus, one month after the first con- 
finement. In an article by Dr. Fordyce Barker (The American 
Medical Monthly, November, 1855), a case is reported dating about 
the middle of the last century, which the author himself thinks to be 
rather apocryphal. Mary Anne Rigaud, of Strasburg, 37 years old, 
was delivered on April 13, 1748, of a living, full grown male child ; 
lochial and milk secretion stopped soon afterwards. On September 
16th, i. e., 5 months afterwards, the lady gave birth to another full- 
grown, living, female child. The autopsy, which was performed pub- 
licly, gave evidence of one single unicornous uterus. Dr. Barker, 
in the Brit, and Foreign Med.-Chir. Review, V. III., mentions another 
case : Gattera Baratti, mother of 6 children, was delivered on Feb- 
ruary 15, 1817, of her seventh, and on March 14th, in the same year, 
of her eighth child. Shortly before confinement, it was observed 
that her abdomen presented two distinct swellings, separated from 
each other by a longitudinal depression in the mesianline. After the 
first delivery, only the right tumor remained. The woman died of 
apoplexy in the year 1847, when a normal os and cervix uteri was 
found, while the uterus had two cornua, each of which was in con- 
nection with a Fallopian tube. The specimen is deposited in the 
Museum of Modena. The following case was observed by Dr. Barker 
himself. Mrs. X., was born in New York, in May, 1827 ; her menstrual 
courses appeared first, when she was 14 years old, and returned at 
regular intervals at 18 days, lasting from 7 to 8 days. After being 
married in October, 1854, she had her courses only twice, when on July 
10, 1855, she gave birth to a healthy, full-grown male child. The lochial 
discharge lasted for only one week, and she nursed her baby well. Still 
her abdomen continued unusually large, and she thought she felt 
quickening on the left side. On September 22d, 74 days afte,r the 
birth of the first child, she was delivered of a female child. The 
lochial discharge lasted for three weeks, still the mother continued 
nursing both her children. Upon examination on Oct. 24th, vagina 
and uterine neck were found in normal condition. Simpson's probe 



189 

introduced into the womb, could be felt through the abdominal walls 
two inches above the symphysis pubis in the left fossa iliaca, the 
cavity of the womb measured 4£ inches. After the probe was with- 
drawn it could also be introduced into the other cavity, its point 
could be felt one half of an inch above the symphysis pubis, towards 
the right side of the abdomen, for a distance of about one inch from 
the mesian line ; this second cavity measured 31 inches. Dr. Kannon, 
(New Orleans Medical and Surgical Journal, May, 1855), was called 
to a woman in child-bed, who had been delivered on the morn- 
ing of the same day. The womb was empty and well contracted, 
the afterbirth removed. Dr. K. in examining the patient, detected a 
second os uteri near the symphysis pubis and a head presenting. As 
no pains were present, the operation of turning was tried, but could 
not be executed, and as the child was dead, it was removed by the 
hook. Both uterine cavities were separated from each other by a 
horizontal septum, of which the posterior one had a normal position, 
while the anterior one was situated much higher. This case is inter- 
esting, because the womb was divided in one anterior and one pos- 
terior cavity, instead of two lateral compartments. After these ob- 
servations, a superfetation in a uterus bi parti tus seems to be possible. 
Dugniolle (Jour.de Med. de Bruxelles, March, 1843), remarked that 
a young woman with double vagina and double vaginal portion, had 
a bloody discharge from both sides during the menstrual period. 
Oldham (Gays 1 Hosp. Reports, October, 1849), has observed the same 
coincidence, and in the case alluded to, during pregnancy of the 
one womb, the other stopped menstruating. 

From this it appears, that a decidua is formed in both sides of a 
uterus duplex, by which also the empty cavity is closed, thus pre- 
venting another conception <$ therefore, the chances for a superfeta- 
tion in cases of this nature, exist only for a short time, i. e., up to 
the formation of the membrane decidua. 

Dr. Sims' uterine elevator is intended to be used for elevating a 
retroverted uterus. The instrument is about thirteen inches long, 
and consists of a handle, a shaft, and a uterine stem inserted into a 
ball, which revolves at the end of the shaft, its axis being at right 
angles with that of the instrument. The ball is of ivory, about five- 
eighths of an inch in diameter, and has a belt of perforation three- 
sixteenths of an inch apart, extending around in a line with the 
stem. The shaft is a hollow cylinder containing a rod which is re- 
tracted at will by the slide, or pushed forward by a spiral spring, so 
that its point may lodge in any one of the perforations in the ball, 
whereby the stem may be held firmly at any desirable angle with 
the shaft. In using the instrument, the stem is set at the required 
angle with the shaft, and thus passed into the retroverted uterus, 
with the ball close up to the os tincse. Then by pulling back the 
slide, the rod is drawn out of the perforation in the ball, when it is 
free to revolve in the direction opposite to that of the motor power, 
and thus the uterus is revolved directly upwards. 

After a short analysis of the cauSes, symptoms, and pathology of 
uterine flexions (ante and retro-flexion), Dr. Holst proceeds to explain 
his mode of treating these affections. The treatment must be a gen- 



190 

eral and a local one. In the first cases which came under Dr. Hoist's 
observation, he applied the self-retaining instrument (redresseur) of 
Kimsch Mayer. — The introduction of the instrument and the reposition 
of the womb was never connected with any difficulties. But most of the 
women under treatment could not endure the presence of the instru- 
ment for any length of time. Violent pains, and spasmodic and hysteri- 
cal disorders followed every protracted application. He therefore di- 
minished the size and elasticity of the two upper arms, by which plan 
he succeeded so well, that most women could bear it sufficiently in the 
uterus. But, although he applied it for three or four hours daily, dur- 
ing several months, he could not record one single case of recovery, 
notwithstanding the simultaneous application of proper internal 
remedies. He therefore entirely changed his former plan of treating 
these malpositions, and with far better results. Above all, a course 
of general treatment was ordered, with a view to strengthen the 
system and relaxed state of the womb. The remedies used were 
cold and sea bathing, iron, ergot, and injections of cold water, by 
means of a strong douche. By making use of these remedies for 
many months, and even years, the patients became strong and 
healthy, menstruation regular, without pains, and the fluor albus 
stopped entirely. Of fourteen patients who were treated in this 
manner, all derived great benefit, while in two of them, the local 
disease (one ante-flexion, one retro-flexion), was entirely cured. 

In the case reported by Dr. Castex, the inversion took place im- 
mediately after confinement, and was reducedin the following way : 
Two strong men seized the patient, and kept her suspended by the 
legs, head downwards. In this position, the womb was brought to 
its proper place, after it had been well oiled, by a midwife. 

Dr. Verity's case is so interesting, a*id so graphically described, 
that we give its history in full. Mrs. R. was about forty years of 
age, and the mother of nine children ; her figure was squat and 
round, showing a large roomy pelvis ; the abdomen pendulous ; her 
health strong and rugged. She was taken in labor with her tenth 
child, and, while walking up and down, a sudden pain expelled the 
child, which fell on the floor, and was not materially hurt. Not so, 
however, the mother : the same pain which forced the foetus from 
the uterus, " brought down," to use the words of the messenger who 
came for me, " the whole of her inside." I arrived at the scene of 
the accident about an hour afterwards. I found the woman lying on 
her back, on a mattress placed on the floor, deluged in blopd. She 
was moaning and sighing, tossing her arms wildly about, and gasp- 
ing for cold air. Her pulse could scarcely be felt at the wrist, and 
her countenance was blanched and ghastly. When the nurse turned 
down the bed-clothes, I was stunned ; I saw before me my first, and 
I devoutly hope my last case of " inversion of the uterus." Occupy- 
ing the space between her thighs, and nearly reaching down to her 
knees, was a large red membraneous looking mass, from which blood 
was oozing, and at its lowest part (the fundus), almost disguised by 
clotted blood, was attached the placenta. I immediately adminis- 
istered a tumbler of spirit and water, with tr. opii in it ; applied 
warmth and friction to the extremities, and, without waiting, forth- 



191 

with proceeded to reduce the uterine mass to its proper position. 
After cleansing it from the clotted blood, the question arose in my 
mind, shall I reduce without removing placenta or not ? Fearful of 
increasing the haemorrhage, I determined to reduce with the placenta 
attached. Recollecting the rules laid down in the books, I began the 
attempt, and an attempt it was only. As soon as I touched the 
uterus, it contracted and shrank, and gave me the feeling as if I was 
holding a live eel in my hand. I tried two or three times gently, but 
firmly, to reduce it according to the usual directions ; but I made not 
the least impression on it. The weight of the placenta bothered me 
greatly ; for, on attempting to return the part that had last pro- 
truded, it was constantly dragged out of my fingers by the weighty 
placenta. I now determined to remove the placenta, and reduce the 
uterus by pressure on the fundus . I quickly detached the placenta, 
and was most agreeably surprised to find there was very little 
haemorrhage ; in fact, after it was removed, the mass shrank in 
volume. I now placed my left hand and forearm under the organ, and 
supporting it in a line with the proper axis, with my right hand half 
shut, I pressed the tips of my rounded fingers firmly against the fun- 
dus, and pushed it upwards, while my fingers were arrested by the 
constricted os. I made firm, but cautious pressure against it, and in 
about half a minute I felt it yield. I then boldly carried my hand 
upward in the axis of the pelvis, and when my wrist was passing 
the constricted os, the fundus suddenly shot from my hand, and the 
organ resumed its usual position. Retaining my hand within the 
uterus for a short time, constriction took place, and the uterus 
returned to its proper state and condition. The woman did well at 
first, but died on the third day, suddenly, after sitting up in the bed, 
for changing her night-dress. 

The subject of Dr. Smith's case was delivered, at the age of 
eighteen, of a first child, and inversion occurred at that time, but 
was not suspected by her attendant. All attempts at replacing the 
uterus failed. The patient was sent to the author of the paper, in 
September, 1856, and symptoms of anaemia existed in the most 
marked degree. She was subject to epileptiform convulsions and 
frequent faintings. On examination, the uterus was found to be 
completely inverted, the neck of the uterus and the os uteri being 
very small and rigid ; the author determined to attempt its reduc- 
tion by continuous pressure, with the intention of dilating or develop- 
ing the os and cervix uteri. With this object, the right hand was 
passed into the vagina, night and morning, and the uterus squeezed 
and moulded for about ten minutes at a time. Chloroform, which 
had been found so useful in cases of inversion of shorter standing, 
was not used, because of the feeble state of the heart and circulation, 
and the comparative absence of pain. In the intervals between 
these manipulations, the vagina was distended, and firm pressure 
exerted upwards by a large air pessary. These means gradually 
dilated the os uteri to such an extent, as to allow of the partial return 
of the uterus, and on the eighth day from the commencement com- 
plete reinversion took place. The subsequent recovery of the patient 
was perfect. She has since menstruated regularly, and is in excel- 
lent health. 



192 

Dr. White's article opens with the history of a case where he re- 
duced the inverted uterus of a woman who had been delivered eight 
days previously. The reduction was perfected at one trial by the 
method of dimpling the most prominent part of the fundus. The 
patient died three days afterwards. The post-mortem examination 
revealed no cause of death, unless the anaemic condition of the 
tissues may be considered as such. A second case under the 
author's care was reduced soon after the accident. A third case was 
not visited until the fifteenth day, no effort at reduction being 
attempted. 

On the 12th of March, 1858, Dr. White was requested, and saw a 
case of inversion of more than five months' standing, in consultation 
with Drs. Kobinson, Reynals, Batten, and Dimick. On examination, 
the fundus was found just within the os externum, the body and neck 
of the organ occupied the vagina ; the inversion was recognized as 
complete, and the organ scarcely larger than when in its natural 
position six months after delivery. The patient being placed hori- 
zontally across the bed and chloroformed, Dr. White introduced his 
right hand into the vagina, and firmly grasped the entire body and 
neck of the uterus. At the same time a large rectum bougie was 
carried up and also received into its palm, and held firmly in contact 
with the fundus of the uterus. Continuous gentle pressure was now 
made upon the external extremity of the bougie with the left hand, 
whilst the right compressed the uterine tumor. In this way the force 
was directed in the axis of the pelvic cavity, putting the vagina 
completely upon the stretch. After persevering in this effort as long 
as the strength of the operator could afford it, the tumor at length 
began to shorten at its neck, and the mouth of the uterus to push 
upon the upper surface of the hand. No depression of the fundus 
was at any time perceptible. At last the fundus passed out of the 
hand, and was easily pushed by the bougie through the neck of the 
organ up to its proper position. The full reduction of the uterus 
was afterwards demonstrated by the uterine sound and the spec- 
ulum. The bougie was retained in the uterus till the next day by 
the attending physicians, and ergot given to promote tonic contrac- 
tion of the uterus. The patient afterwards recovered entirely. 

In concluding this highly interesting paper, Dr.' White remarks 
that the reduction by dimpling the fundus ought to be restricted to 
recent cases, as in those of old standing the uterine cavity left is too 
small, and the organ too firm, for any depression to be made upon 
the walls of the fundus. 

Dr. Jobert, in a lecture on prolapsus uteri, rejects the use of pessa- 
ries altogether. He does not seem to have given them a fair trial, nor 
does he seem to be sufficiently acquainted with the different forms of 
instruments in use for prolapsed uterus. 

At a meeting of the Berlin Obstetrical Society, Dr. Mayer read a 
paper on the removal of the uterine neck for the cure of prolapsus. 
In those cases of falling of the womb which are accompanied by en- 
largement of the neck of the uterus, every sort of mechanical treat- 
ment is contra-indicated, partially because the pessary cannot be 
placed in a fit position, partially because in most cases it can be 



193 

endured only for a short time, owing to the great pain following its 
application. The best and safest remedy for this hypertrophy is am- 
putation of the neck, which has been executed several times by Dr. 
Mayer. In performing it, the womb is drawn downwards as far as 
possible by strong hooks, and the diseased portion removed by the 
knife. This is generally followed by profuse hemorrhage, which is 
promptly arrested by the actual cautery. The after-treatment is that 
of a plain cut wound ; pledgets of lint, well covered with oil, are 
applied to it ; the vagina is to be cleansed frequently by injection ; 
the wound to be brushed over with a solution of nitrate of silver, and 
the womb, which generally contracts after the operation, to be retain- 
ed by a lint plug. 

These views were illustrated by the report of a number of cases in 
which this operation was performed, and have proved successful. In 
a discussion which followed, it was suggested and accepted, that 
these operations might have been performed, just as safely, if not 
more so, by the dcraseur. 

[The use of the dcraseur is now in the very hight of fashion ; but 
when the excitement has cooled down, its use will be restricted to 
the proper cases. The writer is of opinion that the amputation of the 
neck of the uterus for curing prolapsus, when executed by the knife 
and actual cautery, will be followed by better results than when per- 
formed by the dcraseur. In the cases referred to, the entire womb 
participates more or less in the hypertrophy of the neck, and, there- 
fore, a good depletion following the cut, and the application of so 
strong an agent as the hot iroh, must be of good service to the 
remaining diseased portion, while the dcrasement is followed by 
scarcely any reaction. — E. N.] 

Dr. Huguier remarks that, in most cases where the womb appears 
outside the external orifice, this is not owing to a prolapsus, but 
generally to a partial or total hypertrophy of this organ, the fundus 
uteri remaining in its usual position, while its cavity is enlarged. The 
neck of the womb is lengthened only in its vaginal portion or in its 
full extent. To prove the correctness of his opinion the author 
reports a number of observations, and expresses his belief that, 
among thirty cases, scarcely a single true prolapsus may be found. 
The only remedy justifiable for this condition is the amputation of the 
neck of the womb, which he performed successfully in thirteen cases. 

Dr. Bonorden believes that the most common cause of prolapsus is 
hypertrophy of the womb, and relaxation of the round and' lateral 
ligaments, and he tries to remove these morbid conditions by the fol- 
lowing treatment : the patient begins to take every day the following 
powders : R. secal. cornut. gr. iii., gummi galbani, gr. x., decreasing 
the quantity as the disease lessens ; at the same time a mistura 
oleoso-balsamica is rubbed over the mons veneris, the thighs, and 
vulva several times a day. Two cases are reported in which the 
treatment proved successful. 

Dr. Kunkler reports three cases of prolapsus uteri, which were 
benefited by the local application of tannin. He recommends a strong 
solution of tannin in glycerine, to be applied with a cotton plug, and 
rest in a recumbent position till a cure is effected!. 
13 



194 

Dr. Steele, in his able article on prolapsus uteri, strongly recom- 
mends the so-called radical plan for treatment, consisting chiefly of 
rest, local antiphlogistic, and adstringent remedies. If these means 
should fail to effect a cure, the use of a uterine supporter is recom- 
mended, similar to that proposed by Dr. C. Mayer, of Berlin. 

From Dr. A. Mayer's article it appears, that Dr. Zwank's hysterophor 
was applied in two hundred and three cases. Fourteen of these 
women discontinued treatment, because the instruments did not 
agree with them, producing ulcerations and pain ; two patients re- 
moved the instrument on their own account, and sent it back with- 
out giving it further trial ; two preferred an abdominal supporter ; 
and seven cases only offered invincible difficulties to the application 
of the instrument. One of these suffered from a far advanced hy- 
drops ascites. The second patient was so deformed and stiff in her 
limbs, that it was impossible for her to remove and introduce the in- 
strument; a third one could not have an instrument for the same rea- 
son, because her arms were paralyzed. With two patients the vagi- 
na was so irritable, that every instrument created violent pains, after 
it had been born for a short time. In two very old patients the 
vagina was so short and rigid, that even the smallest size could not 
be entirely shut when introduced 

Before an instrument was applied, those complications as could 
be healed (metritis, hyperaemia, hyperssesthesia, ulcerations), were 
first removed. The greatest difficulty was experienced in the treat- 
ment of those occasional ulcerations which are located in the walls 
of the vagina. The application of caustics, nitrate of silver, etc., 
was always followed by an aggravation of the symptoms, while re- 
peated scarifications, and the use of acid, pyrolignos. succeeded 
better, though after a considerable length of time. 

Simple hypertrophies of the womb, as a general rule, did not inter- 
fere with the successful application of Dr. Zwank's instrument, while 
in those cases, where hypertrophy and lesions of the womb were 
combined, the greatest difficulties presented themselves to the use 
of the hysterophor — such as violent back-ache, bearing down, in- 
creased painfulness of the womb, ulcerations of the labia and vagina. 
In these instances the womb has to be first replaced by the probe, 
and retained in its position for some time by a plug, introduced into 
the vagina, after which an instrument may be tried again. 

The leading point in searching for the right size of the instrument 
is the space and direction of the arcus pubis, an average shape of 
which may be acquired by the introduction of the second and third 
fingers, thus establishing the distances of the two pubic bones. Very 
often a comparatively small instrument is required for retaining 
very extensive prolapsus. This remark applies also to cases of pro- 
lapsus combined with rupture of the perineum, which are very often 
benefited by a small instrument of Zwank, while all the other kinds 
failed to retain the womb in its position. Still the question, if the in- 
strument is of a fitting size, will be lastly decided by the sensations 
of the patient when she has worn it for several days, after the very 
first disagreeable impression of a foreign body in the vagina, are 
overcome. If the instrument chosen is of the right size, the patient, 
after some days, will be scarcely aware of its presence. 



195 

Sometimes it happens that a portion of the vagina works itself 
beneath the anterior edge of the instrument and appears outside the 
vagina. To remedy this, an instrument must be chosen, the greatest 
breadth of which is situated in the centre, i. e. where the two lateral 
wings are joined. By the invention of Dr. Zwank, the bloody opera- 
tion, episiorrhaphy, elytrorrhaphy, the pincement du vagin, etc., have 
been supplanted, because by Zwank's hysterophor almost all cases of 
prolapsus are retained, of whatever shape and size they may be, pro- 
vided the right instrument has been chosen. The conditions which 
forbid the application of Dr. Zwank's hysterophor are : carcinoma 
uteri ; hypertrophy of the neck of the womb ; very narrow, rigid 
vaginal walls, as often met with in very old women ; large pelvic 
tumors ; far advanced hydrops ; some very rare cases of distorted 
pelvis. 

Dr. Savage, in a clinical lecture on prolapsus uteri, mentions the 
following experiments on the dead body. The pelvis having been 
exposed to view, traction was made on the os uteri by means of a 
forceps, introduced by the vagina, so as to make the uterus take the 
ordinary course of prolapsus. A descent of an inch and a half ren- 
dered the cervical ligaments very tense, another half-inch and they 
began to yield. They were now cut through and the uterus descend- 
ed at once another inch. The strain was now found to be sustained 
by the pelvic peritoneal lining, which yielded slowly onwards to- 
wards the broad ligaments, which lastly was only put on the stretch 
when the uterus was drawn well out of the vulva. From these, and 
several other experiments, it appears that the uterus under normal 
circumstances, is retained at a certain elevation in the pelvis by the 
cervical ligaments — these ligaments, and these only, tend to prevent 
prolapsus. The vagina does not in the least support the uterus. 
When not inverted, the direction of the superincumbent pressure 
tends to keep its sides together. In this sense only can it be said 
to prevent prolapsus ; even so it can have no share in doing this, 
until the uterus has lost the support of its cervical ligaments ; on 
the contrary, it is these ligaments that preserve the elongated posi- 
tion of the vagina, which would otherwise, as it does in fact in pro- 
lapsus, shorten into numerous transverse folds. 

With regard to pessaries, Dr. Savage remarks : Simpson's com- 
pound pessary answers perfectly when the patient can bear it, 
which, alas, is very seldom, if ever. The ball pessary is the best of 
all, when the perineal end of the vaginal cone retains its elasticity. 
The best stem pessary, the only active support, is readily made by 
fastening firmly a piece of sponge to one end of* a piece of gutta- 
percha tubing. The opposite end has attached to it four pieces 
of elastic vulcanized caoutchouc, which pass up, two before and two 
behind, to a band round the abdomen, or to the ordinary corsets. 

This latter form is invaluable in some cases, particularly for tem- 
porary use. A small quantity of any injection can be thrown up 
through the tube. It can be introduced and removed by the patient 
herself. Dr. Zwank's pessary finds its way invariably where it is 
intended to go. The patient can manage it herself without difficulty. 
The screw was found an objection, and Mr. Russell, an instrument- 



196 

maker has made a substitute, which renders Zwank's pessary the 
most perfect yet devised. 

In those cases where pessaries cannot retain the prolapsus, the 
episiorrhaphy, must be performed. After a short his'torical analysis 
of the various surgical plans for treating prolapsus uteri (Marshall 
Hall, Diefferibach, Evory Kennedy, Phillips, Desgranges, Fricke, Oed- 
dings, Brown), Dr. Savage proposes his own method, which is a 
slight but important modification of Geddings' operation and which 
was applied successfully in eleven cases. Having, by pinching up 
more or less of the flaccid vulva, carefully ascertained how much in- 
tegument may be removed, a flap of suitable size is marked off by a 
sharp scalpel, and then dissected away, commencing with the skin, 
and ending with the vagina ; the entire thickness of which, however, 
is taken away as far as the perineal fascia, after which the raw sur- 
faces are united by quilled suture, and five or six points of inter- 
rupted suture, which are removed on the sixth day. 

Dr. Toland reports a case of prolapsus uteri treated by excision of 
stripes from the vaginal walls. The patient is pronounced cured 
two weeks after the removal of the sutures. [We are of opinion 
that four weeks is a time too short to judge of the efficiency of an 
operation of this kind. If a patient with prolapsus uteri has been 
laid up for four weeks, this alone will bring on a considerable 
change in the condition of the parts, compared with their previous 
displacement. This remark not only applies to Dr. Toland's case, 
but to almost all the cases reported in periodicals, and we will never 
get at a fair estimate of what the surgical operation does for prolap- 
sus uteri, unless the operators will give us accounts of their patients' 
conditions at least one or two years after the operations were per- 
formed.— ^E. N.]. 

Dr. Vernon's article is written with a good deal of feeling against 
Dr. Baker Brown, who seems to have touched our author's " corde 
sensible." Two oases are reported of relapsed falling of the womb 
after Baker Brown's operation. 

Dr. Rigby decribes a peculiar condition of the womb, which he 
calls the " squatting uterus," where the body of the uterus is too 
weak to sustain the fundus and the pressure of the intestines upon 
the latter ; it thenceforth must yield in every direction, so that the 
fundus approaches the orifice. The following symptoms are connect- 
ed with the disease : pain behind the symphysis pubis, increased by 
the upright position, extending to the bladder or rectum ; the menses 
are generally very copious. The uterus, upon examination, is found 
enlarged, of a spherical shape, very soft, while the cervix feels hard, 
and is short and painful. • The probe passes the orifice easily, while 
its further advance is generally connected with pain ; the cavity is 
found enlarged, and after the fundus has been elevated to its full ex- 
tent, the probe measures generally 3" at the external orifice, even in 
women who have never been pregnant. The patient feels immediate 
relief as soon as the fundus has been brought to its right position by 
the sound. The treatment of this disease consists chiefly in the 
application of general and local tonics, and rest of the body. 

Dr. Crosse presented a specimen in the Norwich Pathological 



197 

Society, which was taken from a woman, whose uterus had been re- 
moved in 1843 by ligature, by the late Mr. Crosse, in consequence of 
its having become inverted after labor. In August, 1849, this patient 
suffered an attack of profuse hemorrhage, which was checked by the 
internal administration of ergot and plugging the vagina. In 1856 
she became an inmate of the Norwich Bethel, having become des- 
pondent and melancholic and possessed of many delusions. From 
this place she was discharged cured at the expiration of six months, 
but she suffered a relapse the year following, and in October, 1857, 
destroyed herself by hanging. At the post-mortem the ovaries were 
found to be of natural size, occupying a central position, and lying 
almost side by side in the cavity of the pelvis. They had their usual 
relation to the fallopian tubes, which were similarly displaced and 
found to be pervious for several inches. The vagina was perfectly 
healthy and very capacious. The os uteri was normal in its situa- 
tion ; there were several abrasions of its surface ; a probe could be 
passed in through it, to the extent of about one inch and a half. The 
remaining tissues did not appear to have undergone any other mate- 
rial alteration, either in position or structure. 

Dr. Hecker was called to a woman in full labor pains, who was in 
her sixth month of pregnancy ; the fundus uteri could be felt dis- 
tinctly below the umbilicus ; but, by examining internally, no os 
could be perceived, only a slight depression in the anterior laquear 
vaginas, just behind and above the symphysis, while a large, fluctuat- 
ing tumor protruded in the midst of the pelvis, which hardened and 
enlarged considerably with every pain, thus giving apprehension of 
its liability to rupture. While the woman was under the influence 
of an anaesthetic, the doctor introduced his hand into the vagina, and 
at last succeeded, after repeated trials, in pushing the tumor in ques- 
tion up into the upper pelvis. As soon as the tumor began to move, 
another tumor came down from behind the os pubis, which was 
nothing but the presenting bladder. It burst immediately, and two 
feet came down into the vagina, when a living six months' child was 
extracted. 

Dr. Brachet reports the case of a woman who had been treated for 
retroversion of the womb, during thirteen years, without deriving 
any benefit. Being recently delivered of a child, she was ordered 
not to leave her bed for forty days, and to use at once adstringent 
injections, which treatment effected a permanent cure. Another 
woman, suffering from prolapsus uteri, underwent the same treat- 
ment with equal success. 



3. UTERINE AND PERI-UTERINE HEMORRHAGES. 

1. De Vhematocele peri-uterine et de ses sources. Par Albert Puech, 
Doct. en mddic, etc. Montpellier: Boehm, 1858. In 8vo. pp. 102. 

— On Peri-Uterine Hematocele, and its Sources. By A. Puech,<M.D., 
etc., etc. 

2. Puech, A., Hemorrhage of the Fallopian Tube. — Rupture of the 
Utero-Ovarian Plexus followed by Thrombus of the Pelvis. — Gaz. 
Hebd. V. 22.28. 



198 

3. Puech, A., on Apoplexy of the Ovaries. — Gaz. des Hop. 88. 

4. Oulmont, on Hematocele Retro- Uterina. — L'Union. June, 8. 

5. Nonat, on Peri- Uterine Hematocele. — Gaz. Hebd. V. 23. 

6. Trousseau, on Catamenial Retro-Uterine Hematocele. — Gaz. des 
Hop. 12. June, 2. 

I. Becquerel, on Hematocele Peri-Uterina. — Gaz. des Hop. 41. 

8. De Vhematocele retro-utirine. Par Dr. Aug. Voisin. Paris, Ad. 
Delahaye. In 4. de 12T pp. et 4 tabl. 1858. 

— Retro- Uterine Hematocele. By Aug. Voisin, M.D., etc. 

9. Du varicocele ovarien et de son influence sur le developpement de 
Vhematocele retro-utirine. Par le docteur Devalz. Paris, Delahaye. 
In 4. de 241 pages. 1858. 

i — On Ovarian Hematocele and its Influence upon the Development of 
Retro- Uterine Hematocele. By Devalz, M.D., etc. 

10. L. Genouville, on Peri-Uterine Hematocele. — Arch. gen. Oct. 

II. Benuet, H., Hemorrhage during the first Months of Pregnancy. — 
Lancet. January. 

12. Routh, on three Gases of Menorrhagia, two of them depending upon 
the Presence of Uterine Polypi, Successfully Treated. (Samaritan 
Hospital). 

13. De la metrorrhagie symptomatique. These. Par Dr. Letellier, 
Paris, 1858. 

— On Symptomatic Hemorrhage. By Letellier, M.D., etc. 

14. Stanley, A. F., Uterine Hemorrhage from Hour-Glass Contraction, 
after the Expulsion of the Placenta. — Maine Report. I. 5. Octob. 

15. Recherches sur la transfusion du sang. These soutenue devant 
la Faculte" de mddicine de Paris. 1858. Par Dr. P. H. Quinche, de 
Dijon.— L'Union, XII. 122. Oct. 14. 

— Researches on the Transfusion of Rlood. Thesis. By P. P. Quinche, 
M.D., etc. 

16. Wheatcroft, J., on Uterine Hemorrhage, Successfully Treated by 
Transfusion. — Lancet. January. — Brit. Med. Jour. April 16. 

11. Labatt, S. B., on Treatment of Menorrhagia. — Dubl. Jour. May. 

18. Griffith, J. S., on Treatment of Metrorrhagia. — Med. Tim. and Gaz. 
January, 23. 

19. Strange, W., on the Use of Alcoholic Stimulants in Gases of Me- 
trorrhagia. — Lancet. April. 

20. Thomas, W., Alcoholic StimulantM against Post Partum Hemor- 
rhage. — Lancet. June. 

21. On Compression of the Aorta Abdominalis as a Means of Arresting 
Post Partum Hemorrhage. — Monatschr. f. Geburtsk. January. 

22. Breslau, on a Case of Extremely Obstinate Menorrhagia Cured by 
Injections of Liquor Ferri Sesquichlorati. — Monatschr. f. Geburtsk. 
Oct. 1851.— New York Jour. May. 

23. Savage, H., on Obstinate Menorrhagia. — Lancet. Feb. — New York 
Jour. May. 



199 

It has been often observed, that some diseases find a more fruitful 
soil in certain countries than in others. Such is the case with peri- 
uterine hematocele, an accident considered almost exclusively by 
French physicians. And among these it is Dr. Puech, who has en- 
tered quite an original and ingenious way of facing the subject, 
while Drs. Oulmont, Nonat, Trousseau, Devalz, Genouville, and Bec- 
querel, have issued very interesting and important articles on the 
nature of this singular phenomenon. 

Dr. Puech remarks that the disease called peri-uterine hematocele, 
may take its origin from three sources. 1. From a lesion of the 
ovary. 2. From a lesion of the fallopian tube. 3. From a lesion 
of the utero-ovarian plexus. With regard to the first of these causes, 
he remarks that ovarian apoplexy Jwas characterized by an afflux 
of blood towards the ovary, and by a partial or total destruction of 
the stroma, or of the graafian follicles. From the force exercised by 
the afflux of blood, it depends whether the membrane which encloses 
the ovary, is ruptured or not. If the rent opens into the peritoneum, 
the hemorrhage may be instantly fatal, or it may cause a peritonitis 
leading to death, or to an "enkystement" of the extravasated blood. 
If the rupture be formed towards the sub-peritoneal cellular tissue, 
the peritoneum is detached, and an extra-peritoneal pelvic tumor is 
the consequence. But as long as the outer membrane is not severed, 
the blood coagulates in the gland, the serum is absorbed, the fibrin 
remains, and the swelling may finally disappear. In other cases the 
ovarian apoplexy is followed by inflammation, and the pus may be 
discharged through the rectum, or the vagina. In the chapter which 
treats of retention of menses, Dr. Puech reports several cases of rup- 
ture of the uterus, or of rupture of the tubes distended with blood, 
that could not be discharged in consequence of an occlusion of the 
os uteri. Three cases are reported of propagation of the blood from 
the uterus into the fallopian tubes, without occlusion of the os uteri. 
The fallopian tube may be the seat of two different kinds of hem- 
orrhages — one of a physiological, one of a pathological nature. If 
death ensues from the latter cause, the tube is found dilated only 
partially or to its full length, its cavity contains a vermicular clot of 
blood, its mucous membrane has a dark red color, while the entire 
organ is of a violet hue. In some instances, the tube is ruptured. 
The blood extravasated in the tubes, may be emptied into the uterine, 
or into the peritoneal cavity. This tubar hematocele has been ob- 
served in a considerable number of cases, and often in connection with 
ovarian apoplexy. The rupture of the utero-ovarian plexus — be it 
in the course of a uterine or an extra-uterine pregnancy — has the 
same cause, and the same termination as the thrombus of the vulva. 
A varicous disposition of the vessels has not been observed in the 
great majority of cases. The consecutive hemorrhage may be intra 
or extra-peritoneal — always fatal in the former, seldom fatal in the 
latter instance. A hemorrhage of this kind always precedes, but 
does not always constitute a hematocele, a name only proper for 
those instances, where the blood is about to become encysted. Uterine 
hematocele must not be mistaken for a rupture of an extra-uterine 
foetal cyst, an accident described by the oldest authors, and which 



200 

may be called pseudo-hematocele, the sources of a real hematocele 
being an ovarian apoplexy, a hemorrhage of the tubes, or a rupture 
of the utero-ovarian plexus. 

Mr. Puech terminates his memoire on rupture of the utero-ovarian 
plexus, with the following conclusions : 1. Whether occurring dur- 
ing or independently of pregnancy, prior to or soon after delivery, the 
rupture of the utero-ovarian plexus is due to the same causes, and 
leads to the same terminations as that of vaginal thrombus. 2. A 
varicose condition observed in four cases, was wanting in a larger 
number. 3. If death does not take place from the hemorrhage, a 
hypogastric tumor or sanguineous cyst is produced, with the same 
seat, symptoms, and termination as retro-uterine hematocele. 4. 
Judging from the cases collected, this rupture is the most common, 
and the least dangerous cause of retro-uterine hematocele, and like- 
wise it is the one which does least mischief to the generative func- 
tions. The other less common sources of this hematocele are ova- 
rian apoplexy, and hemorrhage of the fallopian tubes. 

Dr. Oulmont gives a very interesting account with a post-mortem 
examination of two cases of retro-uterine hematocele, both of which 
almost recovered under antiphlogistic treatment, when they were 
taken with dysentery. One of the patients died from its effects, while 
the other one was rescued and died afterwards from an extensive 
gangrenous abscess, situated near the uterus. In the latter case, 
both fallopian tubes were enlarged and filled with disorganized 
blood. This circumstance induced Dr. Oulmont to believe, that the 
patient had at first a tubar hemorrhage, in consequence of which 
one of the tubes burst, thus giving exit to the blood into the abdominal 
cavity. In a discussion which followed upon the exhibition of the speci- 
mens in the Socidte - Mddicale des Hopitaux de Paris, Dr. Aran re- 
marked that surgical interference was, generally speaking, injurious. 
His advice was to apply daily a large number of leeches upon the 
abdomen, decreasing their number gradually ; this to be continued 
for eight or ten days. By following this plan he had often seen 
these tumors lessen rapidly in size, although they never disappeared 
entirely. On the other hand, Drs. Barthez and Bourdon reported 
each a case, which was successfully treated by puncture and injec- 
tions ; while Dr. Oulmont again pointed to the fatal results observed 
after active interference, from the practice of Drs. Nelaton, Gosselin, 
Vidal, and Voillemier. 

Dr. Nonat lays a great stress upon the distinction of intra and 
extra-peritoneal hematocele. In the latter form the tumor descends 
between rectum and vagina, below the os tinea ; the neck of the 
womb is pressed against the symphysis, while the fundus uteri is 
soVnewhat elevated. By means of a speculum a violet tumor may 
be seen in the vagina, a symptom of great importance for diagnosis. 
In cases of h. intra-perit., this color is never found in the laquear 
vaginae, and the tumor does not come down very far, while the 
uterus is not pressed forward, but seems to be implanted in the tumor 
itself, which may be perceived surrounding the womb from all sides. 
This distinction is important from a prognostical and therapeutical 
point of view. The hemorrhages extra peritoneum are much more 



201 

favorable. The most important considerations in regard to treat- 
ment are : rest in a horizontal position, strict diet, mustard-poultices 
repeatedly applied to the upper extremities, softening cataplasms 
upon the abdomen, mercurial frictions, slight cathartics, cold water 
dressings upon the hypogastrium and inner part of the thighs, espe- 
cially at the beginning of the disease, in order to stop the hemor- 
rhage. In phethoric women bleeding from the veins may be repeat- 
edly resorted to, while local blood-letting does not seem to do much 
good. Blisters applied to the abdomen are of service in cases where 
the reduction of the tumor proceeds very slowly. With regard to 
tapping, it is important whether the blood is deposited intra or extra- 
peritoneum. This operation will always prove fatal in the former 
instance, while in cases of extra-peritoneal hematocele, the blood has 
to be removed in this way, whenever urgent symptoms seem to de- 
mand our actual interference. Dr. Nonat has applied the trocar 
three times under these conditions, and in every single instance suc- 
cessfully. Like Laugier, he introduces an elastic canula through 
the opening made by the trocar, in order to have the fluid entirely 
removed, and to make injections of water or of tincture of iodine. 
Out of fifteen patients who came under Dr. Norat's care, only one 
died, and in this instance the hematocele intraperitoneum was com- 
plicated with extra-uterine pregnancy. 

Dr. Trousseau, in a lecture delivered at the Hotel Dieu, urges to 
make a distinction between catamenial and accidental hematocele. 
The author does not think that the blood in catamenial hematocele 
was discharged from a ruptured graafian follicle, but rather from the 
mucous membrane of the abdominal orifice of the tube. This is con- 
firmed by the following facts : 1. In post-mortem examinations of 
women, who died from this accident, no lesion of the ovary is dis- 
covered (three cases of Tardieu). 2. In some instances the tubes 
were filled with blood (Oulmont). 3. Mucous membranes are more 
inclined to bleeding than serous membranes. 4. Hematocele is most 
commonly observed in women with an abunflant menstrual flux. 
Accidental hematocele occurs only once in the same person, while 
those females, who had one attack of catamenial hematocele, are apt 
to have relapses of the same disease. These remai-ks were offered 
on occasion of a young lady being received in the hospital with 
hematoc. retro-uterina. This woman was admitted two years ago 
with the same complaint, and dismissed as cured. 

The thesis of Dr. Voisin contains a review of the papers published 
on hemotocele retro-uterina, to which a series of new cases is added. 

Dr. Deralz's paper gives a good anatomical description of the 
utero-ovarian venous plexuses and their varices, while the second 
portion of the work shows the influence of ovarian varicocele 
upon the development of hematocele peri-uterina, which he designs 
as the most common source for this disease. The ovarian veins in 
women affected with varicocele have a decided influence upon the 
tissue of the ovary itself. The lesions, from this disposition, are 
chronic oedema and an excessive engorgement of the entire tissue of 
the gland, because the blood, under these circumstances, scarcely 
circulates in these rigid canals ; it accumulates more ind more, but 



202 

especially under the influence of the menstrual congestion, near the 
ovarian vesicles, where it finds the least resistance.. The organ thus 
swelled with blood, is compressed between its enlarged bulbus and 
the unelastic peritoneum of the small pelvis. If this compression is 
very considerable, the laceration of the ovary, instead of being con- 
fined to one graafian follicle, extends to several of them, in conse- 
quence of which an effusion of blood into the peritoneum is inevita- 
ble. In other cases, the wound left after the rupture of a. follicle, 
instead of being closed up, becomes swelled and fungous, thus pre- 
senting a veritable varicous ulcer of the ovary, analogous to that of 
the leg. 

Dr. Genouville's thesis on periuterine hematocele is a critical and 
historical analysis of all that has been written in France on the sub- 
ject in question. The honor of having first called the attention to 
this disease is due to Drs. Nelaton, Vigue*s, and Bernutz (1848), 
while Trousseau, Puech, Devalz, Gallard, Laugier, and others, have 
contributed considerably towards the solution of the points contest- 
ed. The entire article seems to be devoted to the defense of the 
ovarian theory against M. Trousseau, who considers a tubar hemor- 
rhage as the principal source of hematocele catamenialis. Two 
observations are reported in favor of this theory — one of M. Gue*rard, 
and one of M. Puech. The latter had occasion to perform several 
autopsies of women, who died during the menstrual period. In one 
of these observations a clot of blood protruded from a ruptured vesi- 
cle ; in the other a clot was found between the ovary and the fallo- 
pian tube, and in a third instance, it was lying in the recto-uterine 
cul-de-sac. The chief symptoms of the disease are a sudden pain in 
the lower part of the abdomen, a rapid discoloration of the skin, and 
a considerable decrease in the menstrual discharge. The abdominal 
tumor is situated generally behind the uterus, in a few instances on 
both sides of this organ, while the womb is dislocated upwards or 
laterally. Most of the women suffering from hematocele periuterina, 
had symptoms of dysmenorrhea a before the first attack of the disease, 
owing to a morbid condition of the ovary. The conclusions which 
the author draws from his researches are as follows : — 1. The hema- 
toceles may be divided into two classes — the catamenial and the 
accidental haematoceles — the former being more frequent than the 
latter. 2. All hematoceles are represented by hemorrhages, with a 
tendency to a formation of cysts. One kind takes its origin from the 
rupture of a blood-vessel, one from an alteration of the ovary, and, 
perhaps, from a hemorrhage of the trompe. 3. The treatment of this 
affection must be confined, with some rare exceptions, to allay the 
symptoms and to absolute rest. 

With regard to the cause of bleeding in the first months of preg- 
nancy, Dr. Bennet remarks that it is very often the consequence of 
chronic inflammation and ulceration of the womb. Therefore, it is 
necessary to apply the speculum in cases of this nature. If, on the 
contrary, the cervix uteri is found free from inflammation, and the 
bleeding goes on unconnected with uterine contractions, it is very 
probable that a mole or hydatides are present. Hemorrhages, if con- 
nected with chronic inflammation during pregnancy, have generally 



203 

a good effect upon the diseased condition of the womb, in lessening 
the state of congestion. Dr. Bennet is of opinion that, in all cases of 
returning catamenia during pregnancy, the uterine orifice is the seat 
of inflammatory ulcerations, so that the bleeding cannot be properly 
called a menstrual one. Therefore, a woman who believes herself in 
the family way, notwithstanding the continuance of her courses, is 
very likely not so, if, after careful examination, the cervix is found 
healthy. 

Dr. Routh's article contains an account of three interesting cases 
of uterine haemorrhage. An unmarried lady had flooded considerably 
for some time past, but it was impossible to find out by examination 
the cause of the bleeding. The patient was ordered to take five 
grain doses of acetate of lead, with five minims of tincture of opium, 
some dilute nitric acid and water every hour ; every night a purge 
of sulphate of magnesia, acidulated with sulphuric acid. This effected 
a perfect cure, after a host of other styptic remedies had failed. In 
the second case, a polypus was removed by the eraseur. In the 
third case, the inside of the womb was found studded with small 
polypi ; the uterine cavity was therefore dilated, and the ex- 
crescences removed by a curette with sharp edges. After this, iodine 
injections, and the application of solid caustics, completed the cure. 

Dr. Wheatcroft considers transfusion as the most efficient remedy 
we possess for subduing violent flooding. After giving a descrip- 
tion of the operation, he remarks that the injections ought to be con- 
tinued until the pulse becomes full, and the activity of the heart 
regular. Two cases of successful performance of the operation are 
reported. 

Dr. Wheatcroft reports another case of successful transfusion of 
blood, in a woman who had a violent attack of haemorrhage which 
could not be controlled, neither by the ordinary styptic remedies, nor 
by the use of the tampon. The entire body of the patient was cold 
and blanched, the pulse scarcely perceptible, the breathing gasping, 
great agitation, loss of sight, eyes sunk and leaden. Under these 
circumstances, about two pounds of blood, taken from the husband, 
were injected, which was followed by a remarkable change, the 
color returned, the eye became brilliant, the pulse was perceptible, 
and the agitation disappeared. With the exception of a sensation of 
giddiness and tightness across the brow, the patient felt quite well. 
The tampon was removed, and no blood was lost afterwards. 

In a discussion of the obstetrical section of the meeting of German 
physicians and naturalists, on the value of Drs. Lee and Seutin's 
method of arresting uterine haemorrhage, the obstetricians came to 
the following conclusions : By the compression of the aorta abdomi- 
nalis, a contraction of the uterus is effected, and consequently haem- 
orrhage stopped. But in order to obtain a lasting and sufficient 
contraction, the compression of the aorta must be performed : 1. 
For a certain length of time. 2. It must be perfect. 3. Executed on 
the right spot, i. e., above the issue of the abdominal vessels ; and 
4. The vena cava has to be avoided. As these cannot be accom- 
plished in the living female, this method loses its value in practice, 
while its physiological basis is undeniable. 



204 

Dr. Breslau reports the following case of haemorrhage, cured by 
an intra-uterine injection. In a woman forty-five years of age, where 
the ordinary means had failed to stop an excessive menorrhagia, Dr. 
B. discovered the uterus soft, enlarged, and perfectly bent upon itself. 
He resolved to apply the liquor fer. sesquichl. to the inner surface of 
the uterus. Having first straightened the retroflected uterus, and in- 
serted an elastic catheter as far as the fundus, he injected one ounce 
and a half of the liquor ferri, diluted with an equal quantity of water. 
The injected fluid was retained in the uterine cavity for a minute and 
a half, by the pressure of the fingers at the os around the catheter. 
During the operation, the patient felt a dull, labor-like pain, which 
lasted for two hours. The haemorrhage now suddenly stopped, and 
was not renewed. After some days, brown crumbling clots were 
discharged, but no fluid blood. Seven months afterwards there had 
been no return of menorrhagia. 

After some preliminary remarks on intractable menorrhagia, Dr. 
Savage reports two cases, illustrating a new way of treating this 
complaint. 

Case 1. — A chlorotic woman had never noticed an irregularity in 
the catamenial function till six months after her second and last con- 
finement, when she began to flood, and continued to do so for eight 
months, with the intermission of only one week per time. Every- 
thing was tried, but in vain, by several physicians. Dr. S., on ex- 
amination, discovered nothing but a slight enlargement of the uterus, 
which had a soft feel. Cold hip-baths, oxide of silver, Indian hemp, 
made but a slight impression. An injection of tunnin and alum into 
the womb, brought the menorrhagia to an almost perfect stand still, 
which lasted for four months, when it returned as bad as ever. Now 
the cavity of the uterus was enlarged successively by sponge-tents, 
and the whole of its internal surface scratched away by Recamier's 
curette, by which only a very limited quantity of vegetations was re- 
moved, but instead a good quantity of a jelly-like white, tough, 
transparent mucus. The haemorrhage first increased, but lessened 
considerably after half an hour, and was still less on the following 
day. With a view to destroy more effectually the polypoid vegeta- 
tions, two injections of tinct. iod. 5iii-, at intervals of three days, into 
the uterine cavity were applied, after which the haemorrhage stopped 
instantly. Dr. S. saw the patient nine months afterwards, when he 
learned from her, that the catamenial periods had been perfectly 
natural ever since. Case 2. — A pallid, debilitated woman complained 
of excessive loss of blood at the catamenial periods, during the past 
two years, since the time of a miscarriage. The uterus was soft 
and enlarged. The os uteri was artificially dilated, and two ounces 
of tincture of iodine, with two ounces of water, were injected into 
the uterus. The same injection was repeated every third day for a 
fortnight, after which the haemorrhage ceased entirely, and the 
uterus began evidently to return to its right size. 



205 

4. TUMORS AND STRUCTURAL DISEASES. 

1. Savage, Priestley, Warthington, Hall, Cases, of Successful Opera- 
tions for Uterine Polypi. — Med. Tim. and Gaz. Jan. 30. — Lancet. 
Jan. 

2. Hall, A., Report of three Gases of Uterine Polypi; Successful Opera- 
tions. — Lancet. April. 

3. Shove, [S., a Case of Uterine Polypus. — Amer. Monthly. X. 3. 
Sept. 

4. Beck, Removal of a Polypus Uteri, with the Aid of Internal Reme- 
dies. — Echo-Me'd. Suisse. 2. 

5. Nesfield, St., Excision of a Polypoid Tumor of the Uterus, with the 
Attached Portion of the Cervix Uteri. — Lancet. II. Dec. 

6. Lumpe, E., Removal of a Fibrous Polypus by the Galvanocaustic 
Apparatus. — Wien. Zeitschr. 35. Aug. 30. 

7. Wells, Spencer, Cystic Tumor of the Cervix Uteri, Removed by the 
Ecraseur. — Med. Tim. April IT. 

8. Johns, R., on the Use of the Ecraseur for the Removal of Uterine 
Polypi. — Dub. Jour. May. 

9. Breslau, Extiipation of a Polypus Uteri. — Monatschr. f. Geburtsk. 
XI. May. 

10. Breslau, Removal of a Carcinomatous Vaginal Neck by the Ecra- 
seur. — Scanzoni's Beitr. III. 

1 1. Lewinsky, on Amputation of the Collum Uteri by the Galvano- 
caustic Apparatus. — Wien. Zeitschr. 34. Aug. 23. 

12. New Instrument. — The Polyptome. — Med. Tim. and Gaz. 392. 
Jan. 2. 

13. Ramsey, A., on a large Fibrous Tumor of the Uterus: Enucleation 
and Expulsion. — Edinburgh, Med. Jour. July. 

14. Binz, Fibrous Tumor of the Uterus, Weighing Sixty-Two Pounds. 
— Deutsche Klinik. 

15. Sloane, J., Gastrotomy for the Removal of a Fibrous Tumor of the 
Womb; Death.— Brit. Med. Jour. Feb. ft. 

16. Cazenave, J., Differential Diagnosis of Polypus and Inversio Uteri. 
— Jour, de Bord. April. 

11. Cremen, on Hydatids of the Womb. — Dubl. Jour. May. 

18. Taylor, T. M., Removal of a Tumor from the Neck of the Womb, 
formed by a Portion of the Membranes, Thirty-Six Hours after De- 
livery. — Amer. Jour. April. 

19. Der Gebarmutterkrebs. Eine Pathologisch-Analomische Monogra- 
phic Von Dr. Med. Ernst Wagner. Privatdozent an der Univer- 
sitat zu Leipzig. Mit 3 Tafeln in Stahlstich. Leipzig : B. G. 
Teubner, 1858. gr. 8vo. pp. 169. 

— The Cancer of the Womb, Being a Pathologico-Anatomical Mono- 
graph. By. E. Wagner, M.D., Lecturer at the University of Leip- 
sic. Leipsic, B. G. Teubner, etc. 



206 

20. Wagner, E., Remarks on Tumors of the Uterus. — Arch. f. phys. 
Heilk. I. pp. 504. 

21. Keiller, A., Bemoval of a Cancer of the Neck of the Uterus by the 
Ecraseur. — Edinburgh, Med. Jour. April. 

22. Isaacs, C. E., Case of Cancroid Ulcer of the Os Uteri — Excision of 
the Entire Cervix — Recovery. — New York Jour. IV. 1. January. 

23. Schiih, Cauliflower-Excrescence of the Cervix Uteri and of the 
Vagina, Removed by Galvanocaustic. — Oesterr. Zeitschr. f. prakt. 
Heilk. IV. 42. Oct. 15. 

24. Armstrong, on Cauliflower-Excrescence of the Womb. — Brit. Med. 
Jour. January, 16. pp. 51. 

25. Laurence, L., on Rodent Ulcer. — Med. Tim. and Gaz. 436. 
Nov. 6. 

26. Parker, L., on a Syphilitic Disease of the Uterus. — Brit. Med. 
Jour. May. 

21. Namias, Gr., on Tuberculosis of the Womb and its Appendages. 

Venezia. In 4. (Con Tavola.) 
28. Cooper, H., Case of Rupture of the Uterus in the Third Month of 

Pregnancy, from Tubercular Degeneration of the Fundus. — Brit. 

Med. Jour. Oct._9. 

Dr. Wagner's work on cancer uteri deserves the greatest atten- 
tion of the profession, and we believe that the researches and expo- 
sitions, laid down in these pages open a new era for the study of 
cancer uteri. If we must consider Dr. Virchow as the path-finder 
for the new genesis of structural metamorphoses, we must consider 
Dr. Wagner as his most clever interpreter with regard to uterine 
cancer. Prof. Virchow is the man, who, with one stroke, annihilated 
Dr. Swann's and Vogel's theory of blastema, which up to the present 
day was the turning-point of our pathological researches. The for- 
mation of cells out of a blastema was a theory, Dr. Virchow's " omnis 
cellula e cettula " is a well demonstrated fact. 

The new methods for the removal of tumors, viz.: the Ecraseur 
and the galvano-caustic apparatus, have been applied very success- 
fully this year in a number of unusually difficult and complicated 
cases. 

Dr. Hall reports three cases of uterine polypi, successfully re- 
moved by ligature. In one of them ergot was given at eyery men- 
strual period for eight months, by which contrivance the polypus 
was expelled from the womb so that it could be reached by the in- 
struments. 

Dr. Lumpe's very instructive article gives a striking representation 
of all the difficulties connected with the operation of tying a poly- 
pus. Although everything was tried, and a very ingenious appa- 
ratus was purposely constructed to bring the cutting loop around 
the body of the polypus, it could not be effected, and therefore the 
tumor had to be removed in two sessions, first its lower and then its 
upper segment. Another trouble, almost worse than the first act of 
the operation, was the removal of the first portion from the vagina, 



207 

after it was cut off with the burning loop. At last it was removed, 
but not without rupturing the perineum up to the sphincter ani. 
The patient was a virgin, and the polypus of unusually large size, 
extending the vagina to its utmost capacity. 

Dr. Breslau's case of dcrasement lmdaire is instructive, inasmuch 
as it shows the necessity of applying the instrument as remote as 
possible from the healthy tissue, in order not to injure the vagina or 
bladder. After the patient had been chloroformed and placed in the 
position for lithotomy, the diseased portion was fixed by several 
hooks and a forceps of Museux's, and the uterus pulled down so 
that the tumor came in sight. Now the chain of the dcraseur was 
placed around the tumor, so that it was situated right in the middle 
.between the diseased and the healthy portion. The time consumed 
for the removal of the degeneration was about twenty minutes. But 
an examination of the excised growth showed, that a portion of the 
vagina had been cut away with it, and consequently a hole of con- 
siderable extent was found in the anterior vaginal wall, through 
which a portion of the intestines protruded. After the vagina had 
been thoroughly plugged, the patient was placed in bed and put un- 
der the influence of opium. The rent in the vagina, although at 
least one inch in diameter, closed entirely, and the patient recovered 
very fast considering the circumstances. 

Dr. Lewinsky, after a short historical synopsis of the methods in 
use for the removal of the vaginal portion, remarks that the prin- 
cipal advantage of the galvano-caustic method with Middeldorf 's 
apparatus was not the absence of hemorrhage, but rather the possi- 
bility of easily removing the collum uteri, without bringing it down 
before the os externum. The author believes that by pulling down 
the uterus, the peritoneal folds constituting the spatium Douglasii 
might be possibly injured by over extension, or peritoneal adhesions 
severed from their place of insertion. The peritonitis often observed 
after this procedure may be owing to this expansion of the perito- 
neal membrane. An illustration of this incidence is mentioned by 
Scanzoni (Lehrbuch krankh. d. weibl. Sexualorgane.ip. 254), occurring 
in a patient who had undergone the operation just mentioned. After 
death a rent two inches long was found running across the lowest 
section of the spatium Douglasii. Two similar cases are reported 
by Mikschik. Therefore every method of amputation of the neck, 
which demands a previous dislocation of the womb, is an unsafe 
proceeding. Added is the history of a case, where the vaginal neck 
was removed by galvano-caustic, for a papilloma portionis vaginalis 
( Clark's Cauliflower excrescence). 

A new instrument intended to facilitate the operation of removing 
broad-based uterine polypi has been invented by Dr. Lever. It 
consists of a semicircular blade, cutting by its concave edge, which 
plays freely round a circular joint, placed at the end of a shaft five 
and a half inches long, when worked by a trigger and thumb piece, 
which pushes a slide and lever acting on the blade forward and back, 
the edge of the blade being then passed over the part which is to be 
excised ; the operator may now make gentle traction by means of 
the handle, while by pulling the trigger he causes the blade to 



208 

sweep forward with a cutting movement, for about one and one- 
eight inches. The instrument now becomes a cutting hook ; the op- 
eration may now be completed with this hook by simple traction, or, 
if the base be too broad for this to be done, the lever may be with- 
drawn with the thumb, and the first step of the operation repeated. 

A primipara, under the care of Dr. Ramsey, was delivered in a 
natural labor, of a healthy child, when the doctor in the act of re- 
moving the placenta, detected a large intermural tumor. An explor- 
ing needle was introduced for diagnosis, but no fluid escaped. The 
opening of the trocar, after some days, was found considerably ex- 
panded so as to admit the point of the forefinger, by which the open- 
ing was gradually enlarged, and separation was effected fully 3J" 
around it in all directions, except that a thick and strong fibrous 
band extended from the lower and back part of the tumor to the an- 
terior lip of the os uteri. This band was afterwards divided by the 
urethrotome. Five days afterwards the tumor came away on its 
own account ; it was a large flaccid mass, of about 2| lbs., with a 
strong white investing membrane on all its surface, except where 
its attachments had been separated by direct interference. 

The following is an abstract of Dr. Wagner's monograph on uterine 
cancer : Cancer of the womb is represented by different forms, viz. 
— 1. Primary cancer (of the vaginal portion ; of the cervix or body 
of the womb, without or with subsequent affection of the vaginal 
portion). 2. Cancer communicated to the womb from neighboring 
organs. 3. Cancer of the womb originating simultaneously with 
cancer of other organs. 4. Secondary cancer of the womb. 

A^s to the different characters of cancer, it may be divided into 
scirrhus, carcinoma medullare, epithelial, and colloid cancer. 

The primary cancer of the vaginal portion is more frequently 
met with than all the rest taken together. Its structure is generally 
an intermediate form between scirrhus and carcinoma. Very often 
the carcinoma contains large microscopical alveols (cancer pultace - 
ardolaire). Epithelial cancer is of rare, genuine scirrhus, of very 
rare occurrence, while alveolar cancer is the least frequent of all. All 
these different forms may combine with the formation of small or 
larger tufts on the free surface of the vaginal portion, in which latter 
instance it represents the so-called cauliflower excrescence (Clarke). 
[The writer does not think Dr. Wagner justified in counting the cau- 
liflower excrescence among the cancerous growths. To say the 
least, this point is not yet decided, neither in an anatomical nor in a 
practical point of view. — E. N.] 

Cancer of the vaginal portion takes its origin very likely as often 
from the anterior as from the posterior lip. It is difficult to give a 
decision on this point, as the chance to examine cancer of the womb 
at its early stages is very seldom offered. It seems to be a settled 
fact, that cancer of the vaginal portion does not start from the mucous 
follicles, but rather from the areolar tissue between the muscular 
fibres. This at least is the result of Dr. W.'s researches from a con- 
siderable number of microscopical examinations. In all the cases 
examined, the glandular organs were not diseased ; in most instances 
the cancer had a greater extension in the muscular portion than in 



209 

the lining membrane. The carcinoma medullare appears, in its first 
stages, as an infiltration of the vaginal portion, with a white, hard, 
cartilaginous, or a loose, encephaloid substance, in which the 
original tissue disappears. The cancerous infiltration of the 
vaginal portion, after some time, proceeds towards the neck of the 
uterus, generally seizing upon its entire length and thickness. In 
the greatest number of cases the affection comes to a stand-still at 
the orificium uteri internum, while in some instances the body of the 
womb itself is taken. Sometimes smaller or larger cancerous de- 
posits are found distributed in the body on different points, independ- 
ent of the primary infiltration of the lower uterine segment. The 
decay of the cancerous infiltration consists partly of the common 
softening, partly of its gangrenous destruction. In the latter in- 
stance it looks sometimes like a primary uterine gangrena. 

After the mollification has begun, the vaginal portion is covered 
with superficial or deep ulcerations ; at a later stage the vaginal 
portion has entirely disappeared, representing' one extensive ulcer- 
ation, covered with a dirty, grayish fluid. In other instances the en- 
tire cervix is wanting, so that the body alone is being left. Cases 
of this kind have been taken for ulcus corrodens (phagedaenicum) 
uteri. 

[The author is of opinion that most cases recorded as ulcus phage- 
dcenicum are nothing but secondary stages of cancer, and only very 
few authors ( Rokitansky, Walshe, Ashwell, Forster) sustain its specific 
character. We are surprised to find that Dr. Wagner does not 
mention a well established fact, viz., that by far the greatest number 
of so-called corrosive ulcers are of a syphilitic nature. — E. N.] 

In some few cases the entire uterus, up to its vertex, was de- 
stroyed. 

Generally, the simple mollification is combined with so-called 
moist gangrena, partly as a consequence of disturbed circulation and 
nutrition of the cancer and the original tissue, partly from a putrifi- 
cation of the cancerous fluid, being exposed to the air. 

The gangrenous places of the ulcerated surface are covered with a 
thin, stinking, yellowish or greenish fluid. Sometimes the surface of 
softened cancerous deposits, or of the gangrenous tissue, is covered 
with warty, granular, and very vascular excrescences, which are 
often hidden under a layer of pus, blood, or ichor. These secondaiy 
growths have to go through the same process of softening or gan- 
grenous destruction as the original cancerous infiltration. The con- 
sequences of softening and sphacelous, are hemorrhages from the 
ulcerated surface, cancerous cachexy, secondary diseases (peritonitis, 
thrombosis), and, perhaps, a more rapid development of the cancer. 

In very rare instances the gangrenous process comes to a certain 
.line of demarcation, probably owing to a formation of pus in its 
neighborhood, and representing one form of the so-called partial self- 
healing of some authors. The spontaneous healing of uterine cancer 
is very dubious. Only very few observations (Rokitansky, Kiwisch, 
Schuh, Bochdalek) deserve the attention of the profession. Among 
the varieties of cancer which are rarely met with, may be counted the 
epithelial cancer. Dr. Wagner saw this, form only twice among 
14 



210 

twenty-five cases. This is at variance with the opinion of many 
authors, and of Virchow especially, who holds that the greatest num- 
ber of uterine cancers belong to the epithelial form. Dr. Wagner 
thinks that Virchow's cancroid is not an epithelial cancer, properly 
so-called, but only a variety of carcinoma containing alveols, with a 
regular disposition of the peripheric cells. As long as this point is 
not cleared up, the discussion about its frequency cannot be settled. 

The real scirrhus is seldom found in the vaginal portion. But, 
generally, a harder form of carcinoma is called scirrhus ; and as 
many cases of hypertrophy, induration, and fibroid have been de- 
scribed as scirrhus uteri, it is very difficult to decide as to its fre- 
quency. 

Of gelatinous cancer only some few cases are known. The author 
gives the details of some cases, which came under his own observation. 

Among the changes to which tlie non-cancerous portion of the uterus 
is subjected, whether before the cancer manifested itself, or after its 
appearance, hypertrophy of this organ is most often met with. It 
consists of a uniform increase of all the tissues of the uterus, but 
more especially of the inter-muscular areolar tissue. In some excep- 
tional cases, the superior non-carcinomatus portion of the womb is of 
normal size, pale, flabby, and extremely soft. The mucous mem- 
brane lining the non-affected portion, shows in most instances the 
different forms of catarrh. Fibroid tumors are often found together 
with cancer uteri. The serous membrane of the womb exhibited, in 
all the cases examined, adhesions and false membranes of different 
shape and size, in consequence of which the womb is attached more 
or less to its neighboring organs. 

Primary cancer of the vaginal portion, involves almost constantly a 
smaller or larger portion of the vagina, where it retains its original 
character. In very exceptional cases, cancer of the vagina has been 
observed, without any immediate connection with the uterine affec- 
tion. 

Cancer of the bladder, propagated from the vagina, is of frequent 
occurrence (38, p. a). 

Secondary cancer of the rectum is not so frequently met with as 
that of the bladder (16 p. c), and generally that portion of the rec- 
tum is taken, which is situated opposite the superior third of the 
vagina. 

Carcinomatous vesical, vaginal, rectal fistulae, and so-called car- 
cinomatous cloaks, are not frequently met with (3 or 4 p. c). Cancer 
of the ovaries and the fallopian tubes is not unfrequently met with, 
but mostly in those cases where the fundus uteri has been affected. 
The areolar tissue around the uterus and the small pelvis is very often 
carcinomatous, thus propagating the disease from its original loca- 
tion to the neighboring organs (bladder, rectum, urethra, pelvic 
muscles, periost, and bones of the pelvis). As a consequence of car- 
cinomatous infiltration of the areolar tissue around the womb and 
vagina, may be considered the immobility of the womb, important in 
a diagnostic point of view. 

Cancer of the urethers is pretty often found, its location being gen- 
erally at their lower terminus. 



211 

Carcinoma of the lymphatic glands may be found in about half the 
number of cases of primary cancer of the vaginal portion, of which 
the glands of the pelvis (plexus iliacus externus, plexus hypogas- 
tricus, plexus s^acralis medius and those in the immediate neighbor- 
hood of the womb, ligamenta lata, etc.), take the greatest share. 
The carcinomatous infliltration of these glands is most often coinci- 
dent with a considerable extension of the uterine cancer, and when 
it is far advanced in the process of destruction. This fact is 
explained by the intimate connection of the lymphatics with the cells 
of the areolar tissue. Cancer of the inguinal and mesenterial glands 
belong to the secondary affections, as they are in no direct communica- 
tion with the diseased womb. Cancef of lymphatics has been found 
in some rare instances. In some cases the carcinomatous deposits in 
the liver are so numerous, that the symptoms of the disease seem to 
point more towards an original affection of the liver, than of the 
womb. 

Cancer of tlw blood-vessels is of very rare occurrence, a few cases of 
cancer of the veins are recorded. It is very remarkable that the 
smaller arteries and veins, running through cancerous portions of 
the womb, have been found unchanged in structure. The spreading 
of the cancer towards the neighboring organs does not at all follow 
the course of the blood-vessels or lymphatics. Before the intimate 
structure and connection of the areolar tissue and its cells were suf- 
ficiently known, this fact could not, by any means, be explained 
satisfactorily. 

From these researches, the great frequency of the propagated and 
of the secondary cancers becomes evident, a fact generally dis- 
believed by other authors. Altogether, uterine cancer offers many 
points of comparison with cancers of other (hollow) organs, in the 
composition of whioh organic muscles take a prominent part (oeso- 
phagus, stomach, intestinal canal). 

The non-carcinomatous diseases originating from cancer of the 
vaginal portion, are of equally great clinical and anatomico-patho- 
logical importance, and many symptoms in a case of cancer uteri are 
derived from these consecutive diseases, while the fatal result is very 
often owing to these secondary non-cancerous affections. 

One of the most common diseases in consequence of cancer uteri, 
are the peritonitides, which are often localized, and of an adhesive 
nature. These seizing upon the peritoneum in its full extent, are 
almost always of puriform or septic character. The latter are most 
often caused by the softening or decaying of the carcinomatous infil- 
tration, and are found mostly connected with perforation of the peri- 
toneum, though general peritonitis is not always the consequence of 
this accident, but of other diseases (Cystitis, dilatation of the 
urethers, croup of the rectum, etc.) 

The diseases of the blood-vessels, especially of the veins, are the most 
frequent non-carcinomatous diseases occasioned by cancer uteri, and, 
above all, thrombosis of the veins, the cause of death in one third of 
all cases. The veins most commonly affected, are the venae uterinales, 
vesicales, hypogastricae, iliacae communes et crurales. This throm- 
bosis is most frequently owing to a pressure of the carcinomatous 



212 

areolar tissue of the pelvis, and of carcinomatous lymphatic glands 
upon the medium-sized veins. This may be concluded from the 
fact that these three conditions are remarkably often found com- 
bined. Besides this compression — thrombosis, Virchovfs marantic 
thrombosis is very often met with. It has its foundation as well in 
the general marasmus, which almost constantly follows the last 
stages of uterine cancer, as in the diminished activity of the heart, 
which is partially owing to fatty degeneration, partially owing to 
the violent haemorrhages from the genitals. In other instances, 
many thromboses are the consequence of a dilatation of the rectal, 
uterine, and vesical veins, or of a purulent inflammation of the ves- 
sels. The results of these thromboses are : oedema of one or both 
legs ; purulent destruction of some portion of the cellular tissue ; a 
more rapid softening or gangrena of the superficial layers of the can- 
cer ; ascites ; occlusion of the arteria pulmonalis, with consecutive 
oedema pulmonum, or lobular infiltration of the lungs, or pneumonia ; 
infarctus of the spleen, liver, and kidneys. Other- non-cancerous dis- 
eases, in consequence of cancer uteri, are : inflammation of the heart 
and the vessels ; inflammation of the pericardium ; inflammation of 
the endocardium ; inflammation of the lymphatics ; acute hyper- 
trophy of the lymphatic glands in almost every case ; chronic bron- 
chitis, with emphysema of the lungs ; inflammation of the rectum ; 
dilatation of the urethers and hydronephrosis, owing to a compres- 
sion of the urethers by cancer of the pelvic areolar tissue, or by 
cancer of the lymphatic glands of the pelvis ; other causes are cancer 
of the bladder, cancer of the lower end of the urether, cancer of the 
entire uterus, with considerable hypertrophy ; cancer of the retro- 
peritoneal glands ; acute purulent nephritis and morbus Brightii ; . 
diseases of the bladder ; diseases of the urethra ; oedema and ascitis ; 
diseases of the bones (erosiones, caries, osteomalacia) ; tuberculosis 
of the lungs. 

Primary cancer of the neck of the womb is exceedingly rare. Three 
cases are reported (Druveilheir, Brachet, Virchow). 

Primary cancer of the body of the uterus is also very seldom ob- 
served. The body of the womb is generaly more or less hyper- 
trophied, the inner layers of which seem to be mostly affected. One 
or both tubes are degenerated at their lower end ; in some cases 
carcinoma of the ovaries was observed, in some carcinoma of the 
retroperitoneal and mesenterial glands, of the pelvic cellular tissue, 
of the peritoneum, bladder, rectum, intestines. 

Cancer propagated upon the uterus from neigliboring organs is the 
most frequent form of cancer of the uterus after the common cancer 
uteri. Its starting point is generally in the vagina, — not so often in 
the cellular tissue between uterus, vagina and bladder, or between 
vagina and rectum — in the other pelvic cellular tissue ; in the ova- 
ries ; in the bones of the pelvis ; in portions of the intestinal tube ; in 
the bladder and rectum. This secondary uterine .cancer is always a 
so-called cancerous infiltration. 

Cancer of the uterus forming at the same time with cancer of other 
organs. A few cases are known where cancer of the mamma or the 
ovaries originated jointly with cancer of the womb (Rokitansky). 



213 

Secondary cancer of the womb. It happens most often after cancer 
of the mamma and ovaries, in some instances after cancer of the 
oesophagus, stomach, intestines, liver, lungs etc. It is generally 
represented in the form of one or more small knots, and most com- 
monly found in the serous membrane of the body of the womb. 

Microscopical disposition of cancer of the uterus. Cancer of the 
womb is almost always a so-called infiltrated cancer ; i. e. in the 
tissue of the organ are deposited alveoli, filled with the cancerous 
juice, so that „in most instances no formation of so-called cancerous 
stroma is present. If stroma is found, it always retains the character 
of a mere hypertrophy of the intermuscular areolar tissue, so that 
the original structures are not considerably altered. 

The cancerous alveoli are almost constantly found deposited in 
the areolar tissue, connecting the muscular bundles, never inside of 
them. From that point they spread in every direction, especially 
towards the substance of. the muscles themselves, not so much to- 
wards the inner or outer surface of the organ, so that its lining mem- 
brane is often found intact in a far advanced stage of the disease. 
The areolar tissue near by very large alveoli, does not exhibit a very 
decided fibrous structure, its corpuscula are small, losing their cell- 
ular appearance, and looking more like nuclei; These changes are 
the consequence of a pressure arising from the growing alveoli. 

These alveoli offer different types of construction in different forms 
of cancer. 

1. Inside the normal or very little altered tissue of the uterus, as 
well in its muscularis, as in its mucous membrane, or in the subse- 
rous and serous tissue are found alveoli of a glandular, tubular, jag- 
ged, ovoid, or spherical form. The shape of these alveoli depends 
partly from their mother organ (corps fibro-plastiques) partly from 
the disposition of the neighboring muscular layers, or from the quan- 
tity and situation of the alveoli themselves. The alveoli are closed 
up from all sides and seemingly limited by a membrana propria (the 
condensed border of the areolar tissue). They contain chiefly cells, 
very seldom an intercellular substance (cancerous serum). Those 
cells situated near the periphery of the alveoli are of a more or 
less cylindrical form, and a regular disposition like cylindric epithe- 
lium. They are generally in intimate connection with the alveolar 
margin. The central cells have no exact shape, being polygonal, 
ovoid or round. Sometimes the centre contains nothing but nuclei. 
The increase of the cells proceeds very likely from the cellular layer 
near the alveolar margin : this is proven by the absence of mother 
cells in the central part, and by the presence of cells with double or 
more nuclei and dichotomic.cells in the peripheric portion. This is 
confirmed by the observation, that the fatty metamorphosis and decay 
of the cells does begin in the central portion. The growth of these al- 
veoli follows up the line of the cellular fibres. Still they increase 
not only in a longitudinal, but in several directions, by branching 
out in one or more points. The larger alveoli very often contain 
smaller compartments. The intra-alveolar partition-walls consist of 
fibrous or homogeneous cellular tissue, with several knots, which 
corresponded, perhaps with the location of the formerly existent cor- 



214 

puscula of the cellular tissue. The framework itself is very likely 
not of recent formation, but a residuum of the normal, atrophic tis- 
sue, resulting from the formation of very numerous alveoli in a small 
circuit. The alveoli have no connection whatever with the normal 
glands of the mucous membrane of the womb, they originate from an 
endogeneous growth in the corpuscula of the cellular tissue. This 
is the most common form of cancer uteri. The same structure is 
exhibited in some cases of cancer of the stomach and liver. 

2. The cancer ardolaire pultace" (Cruveilhier) is no particular form 
of cancer, but offers the same anatomical structure under the micro- 
scope as that described above. The thick juice which may be 
squeezed out of it, a maniere de vermisseaux, consists of decayed 
cells, nuclei, albuminous and fatty molecules, with a slight admix- 
ture of cholesterin. 

3. The common carcinoma is not found in the uterus, as often, as 
the first mentioned variety. Its alveoli are seldom very large ; their 
shape is not so very regular as quoted by the majority of authors. 
Its alveoli contain at times very little, at times a considerable quan- 
tity of serum. But, in numerous cases, the cancerous serum is, for 
its greatest portion, an artificial production, owing to a bursting of 
the softer cancerous cells, by manipulation or addition of fluids for 
microscopical examination. The cells of the carcinomatous serum, 
i. e. the so-called cancer-cells, are in many cases single, being loca- 
ted side by side, without any further connection, while in other 
instances two or more of them are firmly coherent with each other. 
This is perfected by the pointed or broad branches, especially of the 
famous cellulse caudatae. In the common carcinoma the contents of 
the alveolus seem to have no other connection with its stroma, than 
the contents of a serous cyst with the wall of cyst. Still, in many 
cases, the intra-alveclar cells are in an intimate connection with 
the wall of the alveolus, with which they are firmly united. 

4. Of so-called scirrhus uteri, only one case came under Dr. Wag- 
ner's notice. The cellular tissue was considerably increased in 
quantity, denser, with fewer nuclei and fibro-plastic corpuscula. 
The muscular stratum between it could not be detected by the eye, 
while it appeared under the microscope, in some places, changed in 
fatty degeneration. The very few alveoli present were generally of 
a large size. Their cells were partly unchanged, partly atrophied. 

The development of the cancer from fibro-plastic corpuscula, the 
author could trace in almost all cases of cancer uteri examined : all 
the different stages, from the undeveloped corpusculum up to a 
mother-cell, with many nuclei and alveolus, could be traced. 

The mollification of the cancer proceeds from the most superficial 
portions, and is altogether the same process going on in cancers of 
the skin and mucous membranes. Its nature is not yet sufficiently 
explained ; it very likely consists in a rapid growth of the cancerous 
cells, and a copious increase of the so-called cancer-serum, which is 
the result of a stasis of the venous blood in most cases. During 
the softening process of cancer, the cells undergo several modifica- 
tions, among which the diffluence of the cells is the most important. 
While suffering this metamorphosis the cells become somewhat 



215 

larger and more spherical ; the cellular membrane is less distinct, 
thinner, disappearing at last entirely ; the contents of the cell become 
more transparent and copious ; the molecules are lying at a greater 
distance one from another ; next the nucleus and nucleoli undergo 
the same metamorphosis. 

In very rare instances Dr. "Wagner observed the so-called mucous 
metamorphosis of the cancerous cells. 

The fatty metamorphosis of the cells is of frequent occurrence, but is 
altogether of very little influence upon the development of the 
cancer. The degeneration starts from the centre of the alveoli, from 
whence it proceeds towards the periphery. 

The atrophy or tuberculization of the cancerous cells is found alone, 
or combined with the other metamorphoses. Its microscopical char- 
acters present nothing extra in cancer uteri. 

Effusions of blood into the cancerous deposits are often ob- 
served. Abundant apoplexies are doubtless one of the causes of 
gangrena cancri. 

Formation of pus is often found on the surface of cancerous ulcer- 
ations ; its origin is not known. In some cases granular growths 
were observed very much like those of common ulcers, in the skin. 

The microscopical characters of non-primary cancer of the womb 
are not yet sufficiently known, but very likely they do not differ 
much from primary cancer of the vaginal portion. 

— This is in short an exposition of the different topics treated of in 
Dr. Wagner's thesis ; it is replete with very numerous microscopical 
examinations ; replete with the best of previous literature ; replete 
with practical hints, and altogether written in a strictly scientific 
and elegant style. We seriously recommend it to everybody who 
takes an interest in the progress of pathological anatomy and gynae- 
cological science. 

Dr. Isaacs removed the entire cervical portion of the uterus, trans- 
formed into one mass of cancroid ulcer by the knife, after which ope- 
ration the severe dragging pains, and other symptoms referable to 
the uterus disappeared entirely. Dr. Isaacs is of opinion that the 
operation will be permanently successful, as cancroid cancer is less 
liable to return than any other form of malignant disease. 

Of the three cases of cauliflower excrescence reported by Prof. 
Schuh, which were removed by galvano-caustic, one recovered, one 
died from peritonitis, owing to a perforation of the peritoneum, near 
the spatium Douglasii, occasioned by the caustic wire. In the third 
case the operation was followed by a severe cystisis and peritonitis, 
from which the patient ultimately recovered. 

Dr. Laurence gives an account of a rodent ulcer, with a post- 
mortem examination. Os and cervix were completely destroyed, the 
remains of the organ of normal size, its tissue somewhat soft and 
pale, but not infiltrated by any morbid deposit. The lining mucous 
membrane of a deep claret hue, and of a pulpy consistence. The 
author holds, that this affection is not of a cancerous or cancroid 
nature, but a disease sui generis. An important symptom during 
life is the state of mobility of the uterus, a condition never present 
in a cancerous affection. 



216 

A case is reported by Dr. Cooper, where a woman died suddenly 
in her third month of pregnancy. On post-mortem examination the 
body was found very plump and well nourished, having nearly two 
inches of fat on the abdominal parietes. The uterus was found to be 
ruptured at the left angles of the fundus. The wall of the uterine 
fundus was so thin, that the part of the placenta remaining in the 
cavity could be distinctly seen through it. The proper structure of 
this part of the uterus was converted into a friable, cheesy, or curdy 
mass, which rubbed away readily under the finger. At the part of 
the fundus above indicated, this change had gone on till only the 
membranous investment was left, and in one part even this had 
given away and produced the catastrophe. The cervix was quite 
healthy and closely contracted. The lungs were not examined. 



VI. PATHOLOGY OF BLADDER, VAGINA, AND 
EXTERNAL GENITALS. 

1. Silver Sutures in Surgery. The Anniversary Discourse before the 
New York Academy of Medicine, etc. By S. Marion Sims, M.D., 
Surgeon to the Women's Hospital. New York : Samuel S. and 
William Wood, 1858. 8vo. pp. 79. 

2. Bozeman, N., Case of Vesica- Vaginal Fistula, with Anteversion and 
K Incarceration of the Cervix Uteri in the Bladder. Replacement of 

the Uterus and Closure of the Fistulous Opening, by Means of the 
"Button Suture." — Communicated with Remarks by Alex. Keiller, 
M.D.— Edijib. Jour. XL. Oct. 

3. Wells, Spencer, Urethro-Vaginal Fistula; Cure by Silver-Suture. — 
Med. Tim. and Gaz. 431. Oct. 2. 

4. Brickell, W., of New Orleans, Two Cases of Vesico-Vaginal Fistula 
Cured. — New Orleans Med. News. V. 9. Nov. 

5. Toland, H. H., Vesico-Vaginal Fistula; Operation and Cure. — Pacific 
Jour. I. 4. April. 

6. Brown, J. B., Three Cases of Vesico-Vaginal Fistula. — Cured. — Med. 
Tim. and Gaz. April It. 

7. Herrgott, Two Cases of Vesico-Vaginal Fistula; one Cured by Su- 
ture and Cauterization; One Healed Spontaneously. — Gaz. de Stras- 
bourg. 4. 

8. Esmarch, on Operation of Vesico-Vaginal Fistula. — Deutsche Klin. 
27. 28. 

9. Two Vesico-Vaginal Fistulas in the Same Patient; Operation; Cure. — 
Med. Tim. and Gaz. Sept. 18. 

10. Simon, G., the Treatment, of Fistula Vesico-Vaginalis, and Vesico- 
Uterinalis. — Monatschrift f. Geburtsk. July. 

11. Simpson, J. Y., Iron-Thread Sutures and Splints in Vesico-Vaginal 
Fistulce. — Med. Tim. and Gaz. 440. Dec. 4. 

12. Savage, on a Mixture of Collodium and Castor Oil for Believing 
the Excoriations in Cases of Vesico- Vaginal Fistula. — Med. Tim. and 
Gaz. Jan. p. 119. — Med.-Chir. Mon.-Hefte. Sept. 



217 

13. Mumm, E., on Obliteration of the Vagina for the Cure of Vesico- 
vaginal Fistula. Thesis. Marburg, 1858. 

14. Neudbrfer, T., on a Tumor in the Urethra of the size of d Pigeon's 
Egg.— Oesterr. Zeitschr. f. prakt. Heilk. IV. 36. Sept. 3. 

15. Wells, S., on Dilatation of the Female Urethra by Fluid Pressure 
—Med. Tim and Gaz. 421. July 24. 

16. Farre, A., on Exfolation of the Epithelial Coat of the Vagina. — 
Beale's Archiv. of Med. II.— Brit. Rev. XLIV. Oct. 

It. Schmidt, E., on a Case of Traumatic Occlusion of the Vagina. — 
Chicago Jour. 

18. Corse, on Cancer of the Clitoris; Operation. — Transactions of the 
Philadelphia College of Physicians. — Amer. Jour. LXXII. Oct. 

19. Falloon, Edw. L., Adhesion of the Labia after Delivery. — Lancet. 
June. 

20. Baker, Brown, T., Ten Cases of Ruptured Perineum Cured by 
Operation. — Med. Tim. and Gaz. 420. July It. 

21. Erichsen and Adams, Cases of Successful Restauration of the Perin- 
eum after Baker Brown's Method. — Lancet. April. 

22. Storer, H. R., Adaption of the Clamp and Button Suture to Pro- 
lapse of the Vagina. — Amer. Med.-Chir. Review. January. 

23. Schultze, B., on Rupture of the Perineum. (With Plates.) — Mon.- 
Schrift f. Geburtsk. XII. 4. Oct. 

24. Mattei, on Laceration of the Perineum. — Prag. Viertelj. Schr. 
October. 

25. Morel and, W. W., Laceration of the Perineum During Labor; 
Operation, etc. — Boston, Jour. LIX. 16. Nov. 18. 

26. Priestley, W. 0., on a Peculiar Form of Laceration of the Perine- 
um During Labor.— bled. Tim. and Gaz. 429. Sept. It. 

2t. Breslau, Incontinentia Urince — Cured by the Removal of Both 
Hypertrophied Nymphce. — Scanzoni's Beitr. B. 3. 1858. New York 
Jour. Sept. 

28. Breslau, Recto- Vaginal Abscess; Recto-Vaginal Fistula; Sponta- 
neous Closure of the Opening. — Mon.-Schr. f. Geburtsk. XI. May. 

29. Ladreit de la Charriere, on Cysts Developing in the Vaginal Walls. 
— Arch. Gen. 

30. Liiders, Removal of a Pessary from the Spatium Douglasii, where 
it had been Implanted and Formed strong Adhesions for several 
Years. — Deutche Klinik, 10. 

This is the age of scientific wire-pulling. In former times they 
were accustomed to use leaden wire — now, in our country, the silver 
wire is universally tried, while on the other side of the Atlantic they 
begin to show a predilection for the cheaper metal, viz.: iron wire. 
The question arises, whether this occupation will be finally bene- 
ficial to suffering humanity or not ? We are happy to be able to re- 
ply in the affirmative. We have received already numerous accounts 
of successful operations for vesico-vaginal fistula. A large number 



218 

of cases which had been abandoned as incurable, were taken up 
with renewed energy, and many an unhappy woman has found per- 
manent relief, who would have been condemned to constant misery, 
had it not been for the excitement produced by the wire. And still 
this blessing is not due to the wire alone. Awakened energy of the 
operators effected the work. The same seemingly happy results 
have been obtained in former times by the silk ; but these have been 
forgotten. The account of operations given by Langenbeck, Dieffen- 
bach, Kiwisch, Wutzer, Simon, Maisonnevue, can boast of the same 
success, of the same average number of cures, although they made 
use of the silk-suture. 

The chief advocate of this modern doctrine is Dr. Sims, of this city. 
His views on the subject are fully expressed in his anniversary dis- 
course before the New York Academy of Medicine. It contains 
some very interesting facts, while the spirit which pervades the 
whole work forcibly reminds us of the times of Oliver Cromwell. 
The speech opens with an anathema against Dr. Bozeman, which re- 
veals a good deal of deep malice towards a man of generally acknowl- 
edged merits, a malice strangely constrasting with the ardent god- 
liness displayed in the rest of the work. After declaring that "the use 
of silver as a suture is the great surgical achievement of the ninteenth 
century " (sic !) the author proceeds to present the proper method of 
using it for the cure of vesico-vaginal fistula. It is called a " clamp 
suture " on account of its method of action, in clamping firmly to- 
gether the surfaces to be united. By perforated shot, compressed 
upon the silver wires, they are secured to leaden cross-bars, or 
"clamps," which burrow in the vaginal tissue ; the whole remaining 
till union by first intention becomes firm, when, by clipping off the 
shots, the sutures are removed. Dr. Sims insists upon passing the 
sutures so far from the edges of the fistula, that the cross-bars would 
burrow in the vaginal tissue. Lately Dr. Sims has discarded the 
clamps and shot, securing the suture by simply twisting the wire. 
The wire must be made of virgin silver, annealed, and small enough 
for a suture. In the majority of operations about the vagina, it is 
better to pass silk ligatures first, and with these to draw the wire 
after. The sutures should be passed in near the edge of the fistula, 
taking care to embrace the whole denuded surface, but not to pene- 
trate the mucous lining of the bladder. They should, in general, be 
about T 3 j of an inch apart, and each tied separately, by twisting the 
two ends of the wire together, then cutting them off, and leaving the 
twisted ends at least half an inch long, to facilitate their removal. 
But the most useful improvement, says Dr Sims, is in the position of 
the patient during the operation. A few require to be placed on the 
knees with the head and thorax depressed f but in the great majori- 
ty of cases the patient may lie on the left side, while the operation 
will be executed with equal facility to the surgeon, and of course 
with more facility to the patient. 

With regard to the importance of silver sutures applied to injuries 
of the vagina, Dr. Sims remarks : "Before this discovery, operations 
for vesico-vaginal fistula were often attended with risk of life, while 
a cure was a mere accident." This bold assertion can only find its 



219 

explanation in the following words on page 48 : "I investigated the 
case (of fistula vesico-vaginalis) thoroughly, reading every author I 
could find on the subject, but to no purpose, for all was darkness 
and confusion." The writer is of opinion, that even a man living as 
far south as Alabama, should not commit himself to the acknowledge- 
ment in such plain terms of his utter ignorance of previous litera- 
ture. But when words like these are pronounced in the city of New 
York, before such a learned body as the Academy of Medicine ; when 
this is expressed in the midst of a professional community, in posses- 
sion of every facility for literary instruction, we can only say, si tacuis- 

ses . If Dr. Sims had taken the trouble to look at the Deutsche 

Klinik, or Prager Vierteljahrsschrift, or Monatsschrift for Gebutsk, or 
Kilian's Operative Midwifery, or La Gazette des Hbpitaux, or one of 
the English Beviews, or even the American Journal of Medical 
Sciences, he would have been easily convinced that every thing he 
has proposed with regard to this operation was known to others be- 
fore him. Neither the needle-holder, nor the speculum, nor the 
position of the patient, nor the results obtained by his way of per- 
forming the operation, are new attainments. The only new propo- 
sition remaining, is the word " silver," instead of silk, lead, or gold.* 
The writer of this was assistant-surgeon to the surgical and obstet- 
rical department of the clinic of the University of Bonn, in 1850, and 
during this time ample occasion was offered to witness the mode and 
results of Prof. Wutzer's operations, which are published in a great 
number of German and English journals. These are so much like 
those laid down in the pamphlet before us, that Wutzer himself could 
not have described them more accurate^. Wutzer's position of the 
patient is entirely the same ; he formerly used the same needle- 
holder, which is now exchanged for a more useful instrument ; his 
speculum represents the same idea, while it allows of even a more 
spacious development of the vaginal sac, as it consists of three in- 
stead of one spatula ; his way of scarifying the edges, and applying 
the sutures, is entirely the same ; and notwithstanding Dr. Wutzer's 
taking silk instead of silver-sutures, his results are entirely the same 
as those claimed by Dr. Sims, i. e., he perfects a cure in the great 
majority of cases. Fig. 6, of Dr. Sims' pamphlet, represents the 
sketch of a fistula, very like one which. Dr. Wutzer operated upon 
successfully, in the presence of the writer, by antero-posterior obliter- 
ation of the vagina. But it is not Wutzer alone ; Kiwisch, Simon, 
Langenbeck, Baker Brown, and many others, are equally successful ; 
and if we must admit, from our own experience, that silver-wire is 
less injurious to the living tissues than silk-thread, we are free to 
say, on the other hand, that the silk-suture does the same service 
with regard to ultimate results. 

The case reported by Dr. Keiller was a fistula of very consider- 
able extent (half a crown in circumference), so that several gentle- 
men, among whom Dr. Spencer Wells, thought it one of the most 
desperate cases for operation. Therefore, no operation was attem.pt- 

* Dr. Mettauer applied leaden-wire for the same purpose in 1847. Dr. Gossett, of 
London, cured a case of vesico-vaginal fistula, by gold wire in 1834. 



220 

ed, and in the course of years the cervix uteri worked itself through 
the opening 1 in the bladder, in consequence of which the womb was 
retroverted and incarcerated, — a condition not detected, while on 
examination the vagina was supposed to be occluded, as no os. or 
cervix uteri could be detected. On August 4th, Dr. Bozeman, of 
Montgomery, Alabama, U. S., undertook the difficult task, and oper- 
ated in presence of Drs. Simpson, Weir, etc. He commenced by en- 
larging the opening on either side, by carefully dividing its extremi- 
ties in a lateral direction by means of an angular-bladed knife. By 
these lateral incisions the cervix uteri became disengaged from the 
bladder, so as to allow its being more readily restored to its normal 
position in the vagina. By means of a small hook the right angle of 
the anterior edge of the fistula was raised, and the mucous mem- 
brane dissected off transeversely towards the left angle. The ante- 
rior lip of the cervix uteri was then pared far in upon the vesical 
side, so as when the sutures were introduced and adjusted, the ten- 
dency to the previously existing uterine displacement might be 
overcome. By means of an ingenious porte-aiguille, seven silk 
sutures were passed* through the now denuded lips of the fistula, to 
the end of each silk thread a silver suture was attached, and the 
former then drawn through, so as to bring the latter into their posi- 
tion. After this Dr. B. cut out a leaden button, shaped and perfor- 
ated it on the spot, and immediately applied it over the sutures, 
fixing the former to the latter by means of seven small leaden bars. 
In manufacturing the button, Dr. B. took care to make a deep notch 
in its posterior edge, for the purpose of better accommodating and 
preventing injurious pressure upon the denuded anterior lip of the 
now replaced cervix uteri. A catheter was now introduced through 
the urethra, to be taken out every twelve hours, and the external 
parts to be syringed with warm water, and again introduced. After 
the operation symptoms of peritonitis set in, and the patient died on 
the sixth day after the operation. The cause of this fatal result was 
found to be a cellulitis starting from a sloughy condition of a small 
portion of the mucous coat of the bladder, at which point cellular in- 
flammation had kindled up, extending subsequently into the sur- 
rounding tissues. The union of the fistular edges was found to be 
perfect, and the position of the uterus all that could be desired. 

Dr. Brickeix's cases of vesico-vaginal fistula were successfully 
treated after Bozeman's method. For diminishing the phosphatic 
deposits in and around the catheter, the author administered benzoic 
acid internally and by injection into the bladder. As to the applica- 
tion of the sutures, Dr. B. passes the needle through the mucous 
membrane of the bladder, and he has observed not the least irritation 
from this procedure. 

Dr. Esmarch reports five cases of vesico-vaginal fistula successfully 
treated by silk suture. He proposes to detach the anterior wall of 
the bladder from the posterior surface of the pubic bones, by the 
vestibular section, in cases of firm adherence of the fistula with the 
ossa pubis. 

A case is reported in the Med. Tim. and Oaz., where two small 
fistulas existed, communicating with the bladder, a little beyond the 



221 

last part of the urethra. Both were successfully operated upon by 
Dr. Foster. 

Dr. Simon read his paper on vesico-vaginal fistula before the meet- 
ing of the Rhenish physicians at Darmstadt, and in order to prove 
more satisfactorily the results of his method, he had invited all the 
women operated upon within three and a half years, and most of the 
number presented themselves to the Society, in order to be examined 
by the members present. 

Of nineteen fistulae, ten were healed completely ; five incompletely, 
i. e., they had to undergo a course of caustic treatment for small 
openings of the size of a pin's head, left open after the operation ; 
only one fistula was sent back uncured ; two women died after the 
operation j a third woman died after a preliminary operation. Of 
the perfectly cured cases, six were treated by the wet suture in 
eight operations ; two by the wet suture, and after-treatment with 
caustic ; two originally very small fistulse were cured by the appli- 
cation of caustic alone. These different fistulse were seated in very 
different locations. 

One was a case of fistula vesico-uterina, t. e., the cavity of the 
uterine neck was connected with the bladder without touching the 
vagina. The incontinence of urine was treated by antero-posterior 
obliteration of the os uteri. The woman is at present quite at her 
ease, while the menstrual blood is discharged through the urethra 
every four weeks. 

Another woman was affected with a so-called deep vesico-uterine- 
vaginal fistula, i. e., the anterior lip of the uterus, and a portion of the 
bladder and vagina, were destroyed. The fistula was cured by 
uniting the posterior lip with the wall of the bladder. In this case 
the menses also flow through the bladder. 

A third woman had a very large fistula, which extended from the 
neck of the bladder up to the os uteri. In this case the loss of sub- 
stance was covered by the anterior lip of the uterus. This woman 
was entirely cured, and afterwards gave birth to a living child. 

Those fistulas cured by cauterization alone were of a very small 
size. 

Of the almost entirely healed fistulas, three were so large that the 
loss of substance involved the entire base of the bladder up to its 
urethral portion, so that the only means left for operation was the 
antero-posterior obliteration of the vagina. All of these women were 
greatly benefited by this operation, i. e., they only lost a few drops 
of urine when exercising too much. 

The only case not cured was that of a woman with a fistula of 
enormous size, where also the sphincter vesicae was destroyed. As 
the union of the fistulous edges could not be effected after several 
operations, episiorrhaphia was resorted to, but a small opening 
always remained, and could not be healed up. 

Two of the women who died aftef the operation were seized with 
pyaemia, while one perished seventeen days after the operation from 
purulent inflammation of the cellular tissue surrounding the bladder, 
uterus, and rectum, with consecutive perforation into the peritoneal 
cavity. 



222 

The conditions on which the successful operations for vesico- 
vaginal fistulas are based are two — 1. The edges of the wound have 
to be approximated in such a manner that they offer a broad and 
healthy surface for subsequent union. 2. The edges must be united 
so that they cover each other entirely, and suffer no undue pressure 
from the suture. As simple as these principles appear to be at first 
sight, they offer very often much difficulty in execution. Some of 
these difficulties have lately been diminished by the manoeuvre of 
pulling down the uterus, by the more complete artificial protrusion 
of the fistula, and by the application of specula better adapted to the 
purpose. 

In order to obtain a sufficiently broad rear surface, the fistula 
must be cut in the shape of a funnel, the point of which is turned in- 
wardly, while its long diameter runs in the lateral diameter of the 
vagina in the greatest number of cases. In cutting out this funnel, 
Dr. Simon pushes a pointed bistoury through the mucous membrane 
of the bladder in a diagonal direction towards the vaginal wall, and 
enlarges the opening around the fistula with the bistoury. He thinks 
that this method (wounding the wall of the bladder) does more 
towards healing, than Wutzer's method, who cuts only the vaginal 
wall. 

For the suture, Dr. Simon applies exclusively a silk thread, be- 
cause the other sutures applied, such as pins, are more difficult to 
use, and often impracticable when the fistula is situated laterally. 

Dr. Jobert's " operation plastique par glissement," by which the lat- 
eral tension of the wound is intended to be overcome, is no longer 
practiced by Dr. Simon. He attains the same purpose by a few sut- 
ures, piercing the vagina at points a considerable distance from the 
wound, while the other sutures, intended for the healing of the 
wound, are placed close to the edges. 

Fistulas of so great a size, that a direct union of their edges can- 
not any more be thought of, must be treated by antero-posterior ob- 
literation of the vagina. The same operation is to be performed when 
they are situated in such a location that a direct union is dangerous 
and giving no chances of success, viz.: those in the roof of the vagi- 
na, where at once the uterus is immovable. 

In performing this operation, all that is left from the lower portion 
of the vesico-vaginal wall, is united with the posterior wall of the 
vagina, thus forming a sac surrounded by the upper portion of the 
vagina, and the anterior and lateral sections of the bladder. 

The antero-posterior obliteration of the vagina has many advan- 
tages over the other methods (episiorrhaphia and transplantation), 
hitherto applied in the same classes of cases ; 1. It offers more 
chances for healing ; 2. It is connected with no danger, as only 
superficial layers of the membranes have to be removed ; 3. It ful- 
fills perfectly what is required, by arresting the incontinentia urinae ; 
4. It has no distressing influence* upon the health or comfort of the 
patient afterwards. 

Dr. Simon has performed this operation six times, and the result 
was better than he expected, viz., only exceedingly small fistulae (of 
the size of a pin's head) were left in some cases, and in all the urine 



223 

perfectly retained, except when the patients indulged in too hard 
work. 

Five very small fistulse were cured by the application of lunar 
caustic, thiee of which were left after the operation. In order to 
have the desired effect of the caustic, the stick must enter into the 
fistula itself, and touch its deeper portions. These cauterizations 
have to be repeated only every second, third, or fourth week. If ap- 
plied more often, the good effect is destroyed. 

In a letter to the editor of the Medical Times and Gazette, Dr. Simp- 
son of Edinburgh, remarks that he has lately operated successfully 
upon several cases of fistula vesico-vaginalis, by using iron instead 
of silver sutures, and substituting iron-thread splints instead of Mr. 
Bozeman's lead-button. The button-suture is intended to prevent the 
lips of the wound being moved by the constant muscular contrac- 
tions in the vesical walls. Dr. Bozeman's plan effectually prevents 
the disturbing effect of such movements lengthwise, or in the longi- 
tudinal direction of the wound. But it has no power to prevent the 
evil effects of such movements, if they occur crosswise, or trans- 
versely to the direction of the wound. The slender oval, iron-thread 
splint, which Dr. Simpson has employed in three cases, overcomes, 
as he thinks, this difficulty, as it so far consolidates the lips of the 
wound, as to prevent them being moved, either in a longitudinal or 
transeverse direction. It is made by twisting ten or twenty wires 
of the size already indicated into an oval circlet or ring, capable of 
including the lips of the fistula-wound, and a few lines of the vesico- 
vaginal septum, on either side, within its concavity. By a common 
borer, two, three, four or more small openings can be made among the 
wires on each side, so as to correspond to the number of sutures used. 
After the edges of the wound are brought together by the adjuster 
of Dr. Bozeman, the splint is fixed by passing first the iro'n-thread to 
its place ; accurately fitting and adapting it there to the parts by 
the finger, and ultimately fixing the sutures across it, tying or twist- 
ing them over the lower bar of this apparatus. When duly adjusted 
and fastened, it appears to compresss and consolidate the lips in a 
way which the plans previously adopted have not so completely 
effected. Besides it is easily made, easily applied, and easily re- 
moved. The wire used for this and as a suture-thread, is the com- 
mon blue iron-wire. It is stronger, cheaper, and altogether more 
easily worked with than silver-wire. 

For relieving the excoriations produced by the urine flowing con- 
stantly over the external genitals and thighs, in cases of vesicova- 
ginal fistula, Dr. Savage recommends the following applications : 
One part of collodium and two of castor oil are mixed together and 
brushed over the excoriated surface of the labia perineum, thighs, 
etc. The mixture forms a soft, smooth coat, which resists for many 
hours the influence of the urine. 

Dr. Mumm in his preliminary remarks on obliteration of the vagina, 
gives a historical sketch of the operations performed (by Vidal, Vel- 
peau, Lenoir, Bdrard, Maisonneuve, Simon, Roser, Breslau, Wern- 
her, Wutzer, Sims), and expresses his opinion that the operation 
ought to be applied only to those cases, where the other usual meth- 



224 

ods are impracticable. After considering the effects of the contract- 
ion following cauterization of wounds, and comparing them with the 
results of some of the operations performed, the author proposes to 
leave the final closure of the wound entirely to nature, thus render- 
ing unnecessary the application of sutures, provided the mucous 
membrane of the vagina has been pared off to a sufficient extent. 
Not in one of the operations alluded to, union per primam was ob- 
served, the obliteration having been always effected secondarily, 
after the sutures had been removed. But in order to promote this 
contraction it is necessary to make the wound sufficiently large to 
obtain a circular instead of a longitudinal contraction. The breadth 
of the surface pared off, must exceed one inch in diameter. In this 
way the operation is considerably simplified ; no particular after- 
treatment is required, and this wound will be closed up, even with- 
out a catheter, as readily as that performed in the perineal operation 
for stone. 

Dr. Spencer Wells has modified Dr. Arnott's instrument for com- 
pressing the prostate by dilating the prostatic portioh of the urethra, 
so as to make it serviceable for the dilatation of the female urethra. 
It consists of a female catheter, a piece of india-rubber tubing fit- 
ting closely over the catheter, an elastic tube furnished with a stop- 
cock, and syringe. On filling the syringe with water, fixing it to the 
end of the elastic tube, and injecting the water from the syringe into 
the catheter, the water is forced through small openings near the end 
of the catheter, and distends the india-rubber tubing which covers it. 
When the syringe is emptied, the stop-cock can be turned, and the 
syringe refilled. The india-rubber dilates at first in a globular form, 
afterwards in a more oblong direction, especially if any lateral pres- 
sure be made on it. In this way the urethra may be very gradually 
dilated until its diameter exceeds an inch. The instrument is intro- 
duced as an ordinary catheter, and so held that the centre of the 
distending portion is kept just within the meatus. In the only case 
where M. Wells applied the instrument the effect was admirable, 
the pain was by no means excessive, and the dilatation did not 
occupy more than ten minutes. 

Dr. Fabre had occasion to examine three membranes discharged 
during menstruation, which in their triangular form were taken at 
first for mucous membrane of the womb. However, they were larger 
than the non-pregnant uterus, and no openings could be found on 
those places where the Fallopian tubes enter, nor the sieve-like ap- 
pearance. Under the microscope it appeared to be one continuous 
layer of flat nucleated epithelial cells, while all the characteristic 
elements of the uterine mucosa were wanting. A second membrane 
of this kind exhibited the same characteristics, and had an undulated 
surface, answering the folds of the vagina. Its shape was cylindri- 
cal with an impression at its upper end from the cervix uteri. The 
third membrane came away from a married lady during menstrua- 
tion. Before it dislodged, the body experienced a pressing sensation 
round the anus, difficulties in the sitting position, and itching in the 
vagina. All these symptoms disappeared with the discharge of this 
membrane. Its character was perfectly analogous to the above 



225 

mentioned, and the depression at its upper termination was a per- 
fect cast of the cervix and labia orificii uteri. From the shape of 
this membrane it? appears that the vagina is a short, flat canal, the 
anterior and posterior walls of which do touch each other, its length 
being 3" ; the width 1" or 1 J". 

Dr. Schmidt communicated an interesting case of traumatic occlu- 
sion of the vagina, before the Cork County Medical Society. The va- 
gina had been totally occluded in consequence of a protracted labor. 
Dr. Schmidt made an incision with a concave tenotome and enlarged 
the opening by a compressed sponge. It was afterwards success- 
fully kept open by a catheter. 

Dr. Schulze's article on perineal rupture contains some very inter- 
esting and orginal views on the subject. During the passage of some 
of the larger foetal parts, the os externum is necessarily violently ex- 
panded. In order to have this dilatation proceed as safely as possi- 
ble, three conditions must be observed : 

1. The extension, which the os externum has to undergo, must be 
as little as possible, i. e. f the head must present to the os the small- 
est possible circumference. 2. The extension must be effected in 
such a way, that the elasticity of the surrounding parts is brought 
to bear in its fullest extent. 3. The tension of edges must be dis- 
tributed equally on the periphery of the os, in order to avoid over- 
extension of some of its sections (perineum). 

With regard to the first named condition, it must be remembered 
that a large size of the head with a small os, and the presentation of 
the head in its small diagonal diameter, with fronting large fonta- 
nels, are circumstances favoring a perineal rupture. The head has 
the same disastrous influence, if it is 'prevented from passing with its 
small diagonal diameter, in or near a horizontal direction (sutura 
sagitalis in the lateral diameter of th*e outlet). In this latter in- 
stance the rupture can be prevented by changing the position of the 
head with the forceps. In other instances the head is prevented 
from passing with its smallest diameter by a too rigid perineum, 
which prohibits the free development of the occiput underneath the 
pubic arch, in consequence of which, it will present with its large 
lateral diameter. In this instance the occiput must be brought for- 
ward under the pubic arch, by a pressure with the fingers to- 
wards the perineum. An early pressure of the perineum by the 
supporting hand must do more harm than good, as it might prevent 
a self-regulation of this malposition. This abnormal direction of the 
head is often caused by a too high symphysis pubis. At times the 
ligamentum arcuatum inferius (ligamentum triangulare urethrae of 
the male ), has the same effect, as a too large symphysis pubis. 
This hindrance is often successfully overcome by a powerful press- 
ure with the hand against the perineum. 

The forceps, instead of favoring a rupture of the perineum, is 
rather a remedy by which we may prevent it, in pressing the occiput 
strongly towards the arcus pubis. To press the left hand against the 
perineum during the extraction of the head with the forceps, is of no 
use at all. The second condition will be satisfactorily complied 
with, if we let the head have a sufficient length of time to pass the 
15 



226 

os. This can be effected by direct pressure upon the advancing 
head, by two or more fingers. With regard to the third condition, it 
must be said, that under ordinary circumstances, the lower point of 
the axis of the foetus, when passing towards the outlet, I'ests upon 
the anus, from which part it is directed upwards, so as to exert an 
equal pressure upon the circumference of the outlet. If the os sa- 
crum is very little curved, if the parts, forming the pelvic basis, 
are too flaccid and pliable, if the pelvis is very little inclined, if the 
pubic arch is too narrow, the axis of the foetus is more or less re- 
tained in its original direction, thus perfecting an undue pressure 
upon the perineum. This evil is often successfully remedied by 
applying the hand to the perineum, and pressing the head towards 
the symphysis pubis. These latter considerations have an equally 
strong bearing with regard to the passing of the shotildej^. The 
upper shoulder must first pass, before the lower one leaves the per- 
ineum, to which we have to apply one hand in order to elevate the 
second shoulder, thus preventing a laceration. From these con- 
siderations, it appears that a pressure of the perineum with the 
hand, is only justifiable in case of a too broad and rigid ligamentum 
triangulare, or, under the circumstances, as mentioned under No. 3. 
But in many instances, these and other manipulations are insufficient 
to save the perineum ; and we must have recourse to incisions, 
especially in those cases where the head is too large, or the vulva 
too small and rigid. One or two incisions of five or six lines in 
length have to be made in the posterior circumference of the vulva, 
in a direction towards the tuber ischi. In very rare instances, where 
two incisions are not sufficient, a third or fourth incision has to be 
added. At times the ligamentum triangulare is so much elevated, 
that the head is prevented from approaching the pubic arch, and in 
this case, Jhe ligament must*be cut into in a lateral direction, and 
about one inch distant from the urethra, in order to avoid the large 
veins in its neighborhood. When these incisions are neglected, the 
upper circumference of the vagina is inclined to rupture, thus giving 
issue to violent and uncontrollable bleedings, when the rupture hap- 
pens to be near the urethra, an accident observed in J four instances 
by Dr. Schultze. The most justifiable time for the lower incisions is, 
when the frenulum begins to give away, while those touching the 
ligamentum triangulare must be made, as soon as the impediment 
begins to show its influence upon the progression of the head. 

But when the perineum has been ruptured, the question arises, At 
what time have we to resort to a surgical operation for its restora- 
tion ? This question seems to be settled now-a-days, viz., the opera- 
tion must be performed immediately after the accident. Dr. Schultze 
openly confesses, that perineal ruptures, injuring the middle or pos- 
terior third of the perineum, had not been of unfrequent occurrence 
during his obstetrical career. Smaller laceratioas heal on their own 
account, while those touching the middle, or even a more consider- 
able portion of the perineum, demand an immediate operation. With 
regard to the latter point, we cannot agree with the author, as we 
have seen repeatedly, that perineal ruptures heal perfectly, even 
when they involve more than two-thirds of the perineum. E. N. — In 



227 

performing the operation, it is generally necessary to cut away those 
portions of the edges which run very uneven, and have suffered from 
pressure. From a comparative application of serres-fires and thread- 
suture, Dr. Schultze came to the conclusion, that the latter gave a 
more perfect union. In thirty cases operated upon, twenty-eight 
united her primam intentionem. With regard to after-treatment, Dr. 
Schultze thinks it unnecessary to keep the patient lying on her side, 
as the lochial secretions, flowing over a well united wound, will not 
prevent a safe union. It is sufficient to make an injection every few 
hours into the vagina, and apply cold water dressings to the per- 
ineum. Equally unnecessary is the application of the catheter, or 
the use of opium, for retarding a motion of the bowels, provided the 
rectum itself is not injured. 

Dr. Mattei presents the following views as to the means of pre- 
venting laceration of the perineum. It is especially necessary, that 
the head passes the vulva in a favorable direction. This can only 
happen when it passes with the necessary degree of flexion. Whilst 
the occiput, passes under the pubic arch, the face has not yet quitted 
the pelvic outlet ; as soon as the upper part of the neck comes under 
the pubic arch the extension of the head (or the separation of 
the chin from the breast) begins. If the distension of the perineum 
begins too early, the head must pass the vulva with unfavorable 
diameters, viz., with the great oblique, or great or straight diagonal 
diameters. Such a passage easily causes laceration. Hence, it is 
the task of the physician to prevent a premature distension by the 
head. This he effects by placing two fingers between the labia, or 
in some cases between the pubic arch and occiput, so as to bring 
the head downwards and outwards, at the same time laying the 
other hand on the hinder part of the perineum, upon which the face 
is lying. This manoeuvre is to be executed during the pains, which 
will thus protrude the head forwards in the requisite position. A 
very simple means of expediting the birth of the head consists in 
compressing firmly the distended perineum with the whole hand. 
This resembles the squeezing-out of the kernel from the cherry. 
On the passage of the shoulders, care must also be taken lest the 
two shoulders pass together. 

Dr. Morland's paper on Laceration of the Perineum is one of un- 
usual interest. He insists upon early operation and the use of 
quilled sutures with interrupted sutures — the latter for the union of 
the deeper portions of the wound. Dr. Morland alludes to the un- 
usually long and broad and rigid perineum as a frequent cause of 
laceration. — We would suggest that this conformation of the perin- 
eum is the very thing where early incisions may prevent the 
rupture. 

The object of Priestley's communication on a peculiar form of 
laceration of the perineum, is to call attention to the occasional 
occurrence of a horizontal or transverse form of laceration, not 
indeed extending necessarily to the cutaneous surface of the perin- 
eum, but implicating the upper or mucous layer, which is situated 
internally, and yet constitutes an important element of the perineum. 
In first labors, as the head descends on and lengthens the perineum, 



228 

two well-defined ridges are found on its anterior free border. These 
ridges correspond respectively — the upper one to the usual attach- 
ment of the hymen or carunculse myrtifbrmes, the lower to the line 
of union between the mucous membrane and the skin. . Thus, at the 
orifice of the vagina, posteriorly, a circular resisting band presents 
itself, which, in exceptional cases, and especially if reinforced by an 
incompletely ruptured hymen, offers considerable opposition to the 
completion of labor, and here the mucous membrane is sometimes 
lacerated in a horizontal direction along the resisting line, implicating 
the orifice of the vagina as if an incision had been made in a circular 
direction, severing the inferior extremity of the vagina from its 
usual junction with, the perineum. One case is reported. 

Dr. Breslau's patient suffered from constant stillicidium urinse 
since her last confinement, complained of a very distressing irritation 
around the pudenda, and a feeling of bearing down in the lower 
pelvis. When examined, the circumference of the external genitals 
and the inner surface of the thighs were found excoriated, very pain- 
ful to the touch, and drenched with urine. Both nymphse were con- 
siderably thickened and several inches long, while the orifice of the 
urethra was enlarged, so as to admit the introduction of the fifth 
finger. A vaginal examination discovered nothing but slight leucor- 
rhcea. Therefore, Dr. Breslau thought that the enormous hypertrophy 
of the nymphae had a paralyzing influence upon the urethra in 
dragging the latter constantly downwards. This was confirmed by 
the report of the patient, who felt the greatest distress when she 
was in an upright position. Under this impression, Dr. B. removed 
one of the nymphge by the dcraseur, and the other some time after- 
wards by galvanocaustic. The patient left the hospital entirely re- 
lieved of all her ailings. 

After a short analysis of the literature, and a minute ana- 
tomical description of the vagina, which presents nothing new, 
Dr. Ladreit enters upon the consideration of those cysts which 
are imbedded in the deeper portions of the vagina. They are 
always situated one inch at least beyond the hymen, and are consid- 
ered by most authors to originate from the vaginal follicles, while 
the author believes the cellular tissue of the vagina to be very often 
the seat of their development. In other instances they may com- 
mence between the muscular layers of the rectum and vagina, or 
between the bladder and vagina. By microscopical examination he 
was enabled to prove the absence of an epithelial layer in those 
more remote vaginal cysts, which is an essential portion of the 
glands and of those cysts, which are situated in the neighborhood of 
the vaginal orifice. They are composed of cellular, fibro-cellular, 
fibro-plastic, and vascular tissue. They result from an inflammation, 
the deposits of which are not transformed into pus, but into a bursa 
mucosa. The most favored place of development is the anterior wall 
of the vagina, and in by far the greatest number of cases parturition, 
or sexual intercourse, had preceded their origin. As long as the 
cysts are small, and situated far above the entrance of the vagina, 
they scarcely give any trouble, and their presence is not noticed by 
the patients. Some have been found as large as a hen's egg ; they 



229 

are mostly of an ovoid shape, with smooth surface ; those originating 
from one of the vaginal glands have a pedicle, and are movable, and 
present themselves at times near the orifice of the vulva. Unless 
they are of considerable size, they do not effect any inconvenience 
whatever, while at times they give rise to a distressing sensation of 
dragging, to fluor albus, or dysuria ; they even, in some instances, 
have presented an obstacle to parturition. The liquid contained in 
these cysts is of a yellow or brown color, and generally contains 
granular globules, which are composed of simple granulations. The 
outer layer of these cysts consists of the mucous membrane of the 
vagina, which is very much distended and discolored. The inner 
layer is composed of cellular and elastic tissue, with a vascular 
stratum, intermixed with a few muscular elements. These tumors 
have been mistaken for prolapsus uteri, hernia vesicas, or recti, 
tumors of the ovaries, etc. Still, by a minute examination, it is not 
difficult to come to a right diagnosis. The treatment of these cysts 
is the same as that applied in hydrocele, be it by excision or injection 
of a stimulating liquid. The article is concluded with the history of 
five cases. 



VII. PHYSIOLOGY AND PATHOLOGY OF THE 

BREASTS. 

1. Traits des maladies du sein et de la region mammaire. Par le Dr. 
Velpeau. 2 me edit. In 8. Avec figures dans le texte et planches 
en taille douce. Paris. 1858. 

— Treatise on the Diseases of the Breast and the Mammary Region. 
By Velpau, M.D. 2d edition, etc. 

2. Albert, A., de diagnosi morborum mammce. Thesis. Gryphiswal- 
dae. 8vo. pp. 31. 

— Albert, A., Diagnosis of the Diseases of the Breast, etc. Thesis. 

3. Berkett, T., on Tumors of the Breast. — Med. Tim. and Gaz. Jan 16. 

4. Fischer, C, Unusually Large Abscess of the Breast. — Zeitschr. f. 
Chir. u. Geburtsh. XI. p. 21. 

5. Harpeck, K., Remarks on the Pathological Anatomy of Cysto-Sarcoma 
Mammce, especially with Regard to its Relation with the Normal 
Structure of the Mammary Gland. — Reichert's Studien. p. 110. 

6. Lee, R., Pregnancy in a Woman, whose Mammce had been Extir- 
pated some years ago. — Med. Tim. and Gaz. July. 

7. Breunig, G., Collbdium against Mastitis. — Med. — Chir. Mon. — Hefte. 
Sept. 

8. Newman, W ; Trend, H. G. ; Miller, and Blythman, Belladonna as a 
Means of Arresting the Secretion of Milk. — Brit. Med. Jour. Feb., 
etc. — Brit. Jour. July. — New York Jour. Nov. 

9. Roussel, Iodide of Potassium for Diminishing the Secretion of 
Milk. — Gaz. des Hop. 15. 



230 

10. Skinner, Th., Arsenic as an Antagalacticum. — Brit. Med. Jour. 
Sept. 11. 

11. Pratt, N. A., Vicarious Action of the Kidneys in the Secretion of 
Milk — Savannah Jour. I. 4. Nov. 

12. Lewald, G., on the Passage of Drugs into the Milk. Thesis. — 
Prager Vihrscrft. XV. 4. 

Dr. Velpeau has published a new edition of his work on Diseases 
of the Breast ; eight hundred new observations are here added to his 
former ones. These are a few of his general conclusions : about one- 
fourth of the tumors of the breast are benign ; though the time is not 
far distant, when they were all regarded as malignant. The left 
breast is rather more frequently than the right breast the seat of 
cancer, and for this there is no assignable cause. It is not correct 
to say that married women are more subject to the disease than 
others. It is also an error to suppose that women who do not nurse 
their children, are more exposed to diseases of the breast than those 
who do ; on the contrary, these affections are three times more fre- 
quent in those who nurse. The constitution, the temperament, the 
character, the social position, the hygienic condition, the mode of 
life, the country, exercise no influence over the production of cancer. 
The nature of cancer, notwithstanding all the efforts of the micro- 
scopists, is still absolutely unknown. 

Dr. Harpeck, in his very ingenious article on cystosarcoma, before 
entering upon the subject itself, presents a minute description of the 
microscopical appearances of the normal mammary gland, its nipple, 
areola, and proper glandular tissue, being taken for the representa- 
tives of a modified integumentum commune. The existence of 
organic muscular fibres in the papilla, which has been denied by 
several authors, can be easily demonstrated, by treating horizontal 
cuts with nitric acid. The lactiferous ducts consist of an epithelial 
layer and a stroma, the structure of which enters into that of the 
gland itself ; the latter consists of vessels, and of a large number of 
longitudinal elastic fibres. A cysto-sarcomatous tumor of the breast 
consists of larger or smaller cavities, imbedded in a bright, fibrous 
stroma, which is accompanied by large vessels. From the inner sur- 
face of the cavities, covered with papillary excrescences, a layer of 
epithelial cells may be easily detached. These cells are replete 
with fat-globules, arranged in a line near the circumference. These 
cavities could be injected with a red substance from the openings of 
the excretory ducts in the papilla. There are two distinct forms of 
the tumor in question, one of a more solid structure, one where the 
cystic structure prevails, which, however, are only different stages 
of development of the same disease. Among the solid forms, those 
of a papillary habitus are the most frequently met with. The pa- 
pillae again are ramified, branching out in different directions. The 
stroma of these ramifications is arranged in two layers ; an inner, 
darker, striated, and an outer granulated deposit of a lighter yellow- 
ish hue. The darker, or immediate stroma of the papilla, contains a 
large number of elliptic, spindle-shaped bodies, arranged in a 
parallel direction with the longitudinal axis of every papilla ; the 



231 

outer granulated tissue is formed by a hyaline blastema, with numer- 
ous short, oval nuclei. From this it appears that the papillae are 
formed by an embryonal cellular tissue, which, towards the central 
part, is combined with a hyaline blastema. Besides this papillary 
species, an areolar one is ofjen observed, the aveoli of which, lined by 
the fibrous, and filled with the granular tissue, pursue a longitudinal 
and ramified course. Another kind of these hollow forms, is charac- 
terized by the want of ramifications and the appearance of a proper 
lining membrane. From a comparison of the microscopical appear- 
ance of cysto-sarcomatous disease, with that of the tissue of the 
normal gland, it appears that it is nothing but a metamorphosis of 
the original constituents of the female mammary gland ; the ductus 
excretorii and large milk-ducts being hypertrophied, while papillary 
excrescences are formed, which increase by sprouting out indifferent 
directions, a process often observed in the cutis and the mucous 
membranes. This excessive growth proceeds from the larger chan- 
nels towards the smaller ones, thus leading to atrophy of the original 
structures of the original cavities in the gland. 

Dr. Lee reports the case of a woman who had given birth to five 
children after her breasts had been removed for scirrhus. In every 
childbed she experienced a strong congestion towards the axillary 
glands two days after delivery. 

Successful applications of extract of belladonna, for arresting the 
secretion of milk, are reported by Drs. Newmann, Trend, Miller, and 
Blythman. The latter gentleman applied it in two cases to one breast, 
while the mothers continued to nurse their babies with the other 
mamma. The best preparation for this purpose is a mixture of equal 
parts of extractum belladonna and glycerine. 

Dr. Breuning has successfully treated two cases of mastitis by 
brushing over the diseased part and neighborhood, collodium every 
three hours. 

Dr. Roussel recommends the internal use of hydro-iodide of potash 
for arresting excessive secretion of milk. A woman who suffered 
from chapped nipples, engorgement of the mammae, combined with 
some fever, was ordered to take the iodine, and by the next day the 
pain and fever had disappeared ; its employment for three days ren- 
dered the cure of a tumefaction, that threatened abscess, complete. 
Dr. Roussel has since then tried it in twenty cases, and always with 
success. The flow of milk returns always three days after the sus- 
pension of the iodide. Its action is more decided in the dose of from 
six to eight grains per diem, than if it is given in larger quantities. 

Dr. Pratt's case of milky secretion from the kidneys is one of those 
which must be received and judged with greatest caution. Although 
the specimen examined was drawn with the catheter, we believe 
that some deception must have occurred. We never can ,believe 
that milk-globules pass through the vessels of the kidneys into the 
bladder, or even from the breast into the blood. Up to the present 
time no milk-globules have been found in the blood, and never will 
be. There is one great defect in the analysis of Dr. Pratt, viz., " No 
urea was found and no uric acid." Now, the woman in question had 
altogether three attacks of this milky secretion, every one of them 



232 

lasting from five to six months. What has become of the urea, and 
is it possible that a woman can live five months without passing any 
urea or uric acid ? 

The following experiments were performed by Dr. Lewald : The 
tincture of chtorid of iron was given to # a goat, in the dose of 20 
drops for a length of time, whereupon the analysis of its milk showed 
clearly the presence of iron. After administering 0,915 grmm. of the 
nitrate of bismuth, this drug could be traced in the milk 36 hours 
afterwards ; three days after the last dose it could no more be de- 
tected. Tincture of iodine, given in the dose of 15 grmm., appeared 
in the milk 96 hours afterwards, and disappeared 72 hours after- 
wards. Two and a half grmm. of hydro-iodide of potash were now 
administered, and iodine traced in the milk t hours afterwards, and 
only on the twelfth day it disappeared. At this time 2£ grmm. of 
the tincture of iodine were given, and 5 hours later the milk con- 
tained again some iodine. During these latter experiments more 
milk was secreted than before. The iodine was never detected in 
the serum, but always in the casein. Arsenic (45 to 50 drops of 
Fowler's solution, repeated twice) was found in the milk after 17 
hours, and disappeared after 60 hours. Sugar of lead could be traced 
after 18 hours. Oxyd of zinc, in the dose of 1 grmm., appeared in 4 
to 18 hours, but disappeared in 60 hours. Tartarus stibiatus was 
traced very soon after its administration, and disappeared after 80 
hours, while the stib. sulfur, aurant. remained 5 days after the last 
dose. After repeated doses of 2 gr. of calomel, mercury was found in 
the milk. Alcohol could not be detected. The milk of a goat, which 
took opium and morphine for three weeks, had no, effect upon rabbits, 
which partook of it. 



VIIL— THE PELVIS. 

1. Lambl, of Prague, the Nature and Origin of Spondylolistesis. — 
Scanzoni's Beitr. Z. Geb. Bd. 3. — New York Jour., Nov. 

2. Breslau, a Contribution to the Knowledge of Spondylolistesis. — 
Scanzoni's Beitr. Z. Geb. Bd. 3. 

3. Hohl, on Kilian's Halisteertic Pelvis. — Deutsche Klinik 24. (Crit- 
ical analysis.) 

4. Whitaker, of Lewistown, N. Y., on Fracture of the Pelvis during 
Pregnancy. 

5. Mann, F., on a Funnel-shaped Pelvis. Thesis. Marburg gr. 8. 

All the pelvis presenting the vertebral sliding, pointed out for the 
first time by Prof. Kilian (see the New York Journal of Medicine of 
May, 1857, p. 389), have been subjected to another thorough anatom- 
ical examination by Dr. Lambl, in order to find out a law explanatory 
of the nature and rise of spondylolistesis, in comparing it with simi- 
lar deformities in other sections of the spinal column. 

1. The pelvis of Prague (described by Kiwisch, Seyfert, Kilian, 
Gurlt), is remarkable for the total absence of disease in the bony 



233 

system, thus leading to the supposition that the remote origin of the 
malformation has to be sought for in the original development of the 
pelvis. The cause of the deviation is founded on the presence of an 
intercalary vertebra, which is a rudimental piece of bone, incuneated 
from behind into the sacro-lumbar juncture. 

2. The pelvis of Munich (described by Breslau) is in many points 
similar to that above mentioned, especially in regard to the anatomi- 
cal disposition of the lumbo-sacral juncture. It presents a hydrorha- 
chitic opening in the spinal canal, and a supernumerary vertebral 
body with consecutive lordosis and partial synostosis of the dis- 
located vertebra with the os sacrum. These supernumerary vertebrae 
may be found at different places in the spinal column, thus effecting 
deviation in many directions. 

3. A large female pelvis in Vienna (described by Rokitansky and 
mentioned by Kilian). The cartilaginous disk of the lumbo-sacral 
juncture has disappeared entirely; the articular surfaces are uneven, 
very hard, and covered with warty f excrescenses. These osseous 
protuberances are owing to a new formation, and are the cause of 
the thorough anchylosis of both vertebras ; upon the anterior edge of 
the first sacral vertebra may be found osseous masses, supporting 
the upper vertebra, which are located symmetrically on both sides of 
the mesial line, thus preventing the vertebral column from sliding 
down any farther. 

4. A small female pelvis in Vienna (described by Rokitansky, 
Spaeth). The most striking feature in this specimen is the compres- 
sion of the first sacral vertebra and the reduction of its hight ante- 
riorly to 3'", so that the lower margin of the last lumbar vertebra is 
situated just opposite the upper margin of the second sacral vertebra. 
Besides this, the pelvis presents hydro-rhachitis sacro-lumbalis, 
with consecutive elongation of arch of the fifth lumbar vertebra, 
parallel to the vertical position of the articular surfaces of the proc. 
obliq. inf., dislocation of the same vertebra in front, lordosis lumbalis 
and pyaemic destruction of the symphysis pubis after metro-phlebitis 
puerperalis. 

5. The pelvis of Paterborn (described by Kilian). It is of a very 
symmetrical form, presenting a clean lordosis of the lumbar portion 
of the vertebral column, without any lateral inflexion. The bones 
look very much like those in osteomalacic basins. No intercalary 
vertebra is present. The fifth lumbar vertebra is elongated in its 
sagittal diameter, forming a semicircle with upper convexity. The 
arch of the fifth lumbar vertebra is of a hydro-rhachitic construction, 
and this is, no doubt, the primary point which caused the dislocation 
of the vertebral body and the lumbar lordosis. 

After a minute description of these five specimens, Dr. Lambl 
mentions — 1. Dr. Robert's observation ( Monatsschrift fur Geb., 1855, 
Bd. 5, Sept. 2, p. 81). 2. The pelvis of Brussels, a description of 
which was obtained by Prof. Gluge. It belonged to a rhachitic 
woman, 42 years old,, who was pregnant with her third child, the 
second one having been delivered with the forceps. The last -time, , 
death occurred suddenly during labor, from rupture of the womb. 
In a post-mortem examination, all the pelvic symphyses were found 



234 

very movable, the bones of the pelvis were very thin, the lower lum- 
bar vertebrae have an anterior flexion (lordosis), narrowing the 
entrance of the pelvis so much, that the fourth vertebra takes the 
place of the promontory. The upper part of the os sacrum is in an 
atrophic and spongy condition, no doubt resulting from , a local 
caries, in consequence of which the sacral bone shrunk, thus permit- 
ting the vertebral column to slide forward. Therefore, this pelvis 
(mentioned by Kilian) cannot be counted among the spondylolistetic 
pelves. Among the pelves with vertebral sliding may be counted — 
a, a pelvis in Paris in the cabinet anatomique de la maison 
d'accouchement ; b, a preparation in the amphitheatre des hopitaux, 
in Paris ; c, a preparation in the anatomical museum of Bonn. 

In opposition to these formations there is a deformity from spon- 
dylistesis and caries, in consequence of which the vertebral bodies 
and their disks are destroyed, while at the same time an osteophyte 
begins to grow up, which tends in a great measure to repair in some 
degree the primary evil ; a preparation of this kind may be seen at 
Montpellier ; lastly, a curious destruction and deviation of the ver- 
tebral column is observed in some instances, viz., kyphosis of the 
lumbar vertebrae, with compensating lordosis of the pectoral ver- 
tebrae. 

Dr. Breslau gives a description of a preparation taken from the 
Musde Dupuytren at Paris, which is intended to show that the pelvic 
deformity called spondylolisthesis (Kilian), may be possibly produc- 
ed by a fracture of one of the vertebrae. The specimen examined 
belonged to a laborer who fell from a tree, first upon his feet and 
then upon the back. The immediate result of the fall was a paraly- 
sis of both lower extremities. Thirteen months later he died in con- 
sequence of pyaemia from a bed-sore. The twelfth dorsal vertebra 
was found fractured in a diagonal direction, presenting an upper 
fragment, which had been reabsorbed in the course of time, and a 
lower fragment of a triangular shape, the basis of which was direct- 
ed and protruded towards the spinal canal. Upon this planum in- 
clinatum the eleventh vertebra had glided down upon the first lum- 
bar vertebra, thus effecting a considerable change in the axis of the 
spinal column. If this same fracture had occurred in the fifth lum- 
bar vertebra, it would have occasioned the same pelvic deformity as 
described under the name of spondylolisthesis. 

Dr. Whitaker reports the case of a fracture of the pelvis during 
pregnancy. A lady, in the seventh month of gestation, fractured 
the body of the left os pubis, by a fall upon an open barrel. The 
fracture united in six weeks, but reopened during labor at the full 
term, and united again. 



235 

IX. GENERAL DISEASES OF WOMEN DURING 
PREGNANCY, LABOR, AND CHILDBED. 

1. De la fievre puerpirale, de sa nature, et de son traitement. Commu- 
nications a VAcademie Imperiale de Midecine. Par MM. Gudrard, 
Depaul, Beau, Piorry, etc., etc. Paris: T. B. Bailliere et Fils, 1858. 
In gr. 8. pp. 462. 

— The Discussion on Puerperal Fever in the Paris Academy of Medi- 
cine, etc. Paris: T. B. Bailliere et Fils, 1858, etc. 

9. On Puerperal Fever. — Discussion in the New York Academy of 
Medicine. — New York Jour. II. 3 ; III. 1 ; IV. 1, etc. 

3. La fievre puerpirale et VAcademie Imperiale de Midicine: Par Dr. 
L. Fleury. In 8vo. Paris: Labd, 1858. 

— On Puerperal Fever and the Paris Academy of Medicine. — By L. 
Fleury, M.D., etc. 

4. Stoltz, A., The Puerperal Fever in the Paris Academy of Medicine. 
— Gaz. de Strasb. 6. 

5. De lafevre puerpirale devant VAcademie de Midicine de Paris et 
des principes du vitalism hippocratiques appliquis a la solution de 
cette question. Par Dr. E. Auber. — In 8vo. de 110 pp. Paris, 1858, 
chez Germer-Bailliere. 

— The Puerperal Fever before the Paris Academy of Medicine and 
the Hippocratic Vitalism with Begard to this Disease. By E. Auber, 
M.D. Paris, 1858, etc. 

6. De la fikvre puerpirale observie a V Hospice de la Materniti. Par Dr. 
S. Tarnier. Paris, 1858. In 8vo. de 208 pages. 

— The Puerperal Fever, as it was Observed in the Materniti. By S. 
Tarnier, M.D., etc. 

I. Pidoux, Bemarks on Puerperal Fever. L'Union, June 5, etc. 

8. Behier, T., on Puerperal Fever. Letters addressed to Prof. Trous- 
seau. — L'Union. 46, 49, etc., etc. 

9. Murphy, W., on Puerperal Fever. Translated in French by Gentil, 
M.D. Paris, 1858. 8vo. pp. 32. 

1.0. Helot, Ch., on Puerperal Fever. Thesis. Paris, 1858. 4to. 

II. Wrotnowsky, J., on Puerperal Fever. Thesis. Paris, 1858. 4to. 

12. Dor, H., on Epidemic of Puerperal Fever at Prague. — Gaz. Hebd. 

13. Surmay, on Puerperal Fever. — L'Union. XII. 99. 

14. Bertillon, A., on Puerperal Fever. — L'Union. 85. 

15. Cros, E., on Puerperal Fever. — Gaz. des Hop. 63. 

16. Dubois, P., on Puerperal Fever. — Gaz. Hebd. V. 18, 19.. 
It. Joux, A., on Puerperal Fever. — Ibid, 49, 51. 

18. Pechalier, on Puerperal Fever. — Rev. Me*d. March, 31. 

19. Levy, G., Belation de Vepidemie de fievre puerpirale, observie aux 
cliniques cV accouchement de Strasbourg, pendant le 1. semestre de 
Vannie scolaire 1856-51. These. Strasbourg, Christophe. 4. 
pp. 119. 



236 

— Levy, G., Report on the Puerperal Fever, Observed at the Obstetric 
Clinic of Strasburg during 1856-57, etc. 

20. Macari, Fr., on Puerperal Fever. — Gaz. Sarda. 

21. Brochin, on Puerperal Fever. — Gaz. des Hop. 81, 84. 

22. Legroux, on Puerperal Fever. — Bull, de Ther. LV. July. 

23. Virchow, on a Puerperal Fever Epidemic, Observed in the ChariU 
of Berlin. (Transactions of the Berlin Obstetric Society). — Monat- 
Schrift f. Geburtsk. June. — New York Jour. Sept. 

24. Lehmann, L., on Puerperal Fever. — Jour de Brux. September 
and October. 

25. Qu'est ce que la fievre puerpirale? Etudes sur les maladies des 
femmes en couche. Par Dr. F. Gallard in 8vo. de 30 pag. Paris: 

Labd, 1858. 

— What is the Nature of Puerperal Fever ? Remarks on the Diseases 
of Women in Childbed. By F. Gallard, M.D., etc 

26. O'Reilly, T., Observations on the Identity of Erysipelas and Puer- 
peral Fever. — Diffuse Inflammation consequent on Erysipelas. — 
Poisoning of the Blood after Parturition. — Amer. Med. Gaz. IX. 
12. Dec. 

27. Noizet, R., Prof Simpson's Views on Contagion and Propagation 
of Puerperal Fever. — Gaz. Hebd. V. 21. 

28. Prosper de Pietra Santa, on the Pathology of Puerperal Fever in 
the Florence School. — L'Union. June, 24. 

29. Tarnier and Vulpian, on the Pathological Anatomy of Puerperal 
Fever.— Gaz. Hebd. V. 17. 

30. Barbran, on Puerperal Metro-Peritonitis. — Thesis. Paris, 1858. 

31. Etudes sur la nature et le traitement des fiver es puerpir ales, des Re- 
sorptions purulentes et des Resorptions putrides. Par de Mattei, 
Prof, partic. d'accouchements. In 8vo. de 51 pag. Paris, 1858. 

— The Nature and Treatment of Puerperal Fever, Purulent and Pu- 
trid Resorption. By Mattei, M.D., etc., etc. 

32. Koch, on Puerperal Metastasis to the Thyreoid Oland. — WUrtemb. 
Corr.-Bl. No. 10. 

33. The Urcemic Convulsions of Pregnancy, Parturition, and Childbed. 
By Dr. Carl Braun, Prof, of Midwifery, Vienna. Translated from 
the German, with Notes, by J. Matthews Duncan, F.R.C.P.E., Lec- 
turer on Midwifery, etc. 12mo., pp. 182. New York, S. and W. 
Wood, 1858. 

34. Pirrie, on Puerperal Convulsions. — Dubl. Jour. February. 

35. Isham, R. N., of Chicago, 111., on Some of the Causes of Puerperal 
Convulsions. — Chicago Jour. I. 10. Oct. 

36. Litzmann, New Contributions to the Doctrine of Urcemia during 
and after Pregnancy. — Mon.-Schr. f. Geburtsk. June. — New York 
Jour. Sept. 

37. Lindslay, C. A., on Puerperal Convulsions. — Transactions of the 
Connecticut Med. Society. May. 



237 

38. Pesch, Case of Puerperal Eclampsia; Recovery. — Mon.-Schr. f. 
Geburtsk. XII. 3. Sept. 

39. Wegscheider, Case of Puerperal Eclampsia. — Mon.-Schr. f. Ge- 
burtsk. XII. 3. Sept. 

40. Paget, Case of Eclampsia. — Gaz. des Hop. 14. 

41. Findlay, W. S., of Fazewell, Term., on a Case of Puerperal Con- 
vulsions. — Med. Report. March. 

42. Boursier, Eclampsia during the Sth month of Pregnancy; Delivery 
of two Children, United by the Sides. — L'Union 14. 

43. Croskery, H., a Case of Puerperal Convulsions; Recovery. — Med. 
Tim. and Gaz. June 19. 

44. Carville, Eclampsia during the 5th month of Pregnancy in a Chlo- 
rotic Primipara; Phlebotomy; Recovery. — Gaz. des Hop. August It. 

45. Dale, W., Three Cases of Puerperal Convulsions; Death and Au- 
topsy. — Med. Tim. and Gaz. 393. January, 9. 

46. Levergood, S., Puerperal Convulsions from Gastric Irritation. — 
Amer. Med.-Chir. Review. II. 2. March. 

46. Wellington, W. W., Puerperal Convulsions. — Boston Jour. LIX. 
18. Dec. 2. 

41. Chapman, E. N., of Brooklyn, N. Y., Cases of Puerperal Convul- 
sions with Remarks upon the Treatment of Eclampsia. — New York 
Jour. V. 3. Nov. 

48. Moreau, L., Compression in the Treatment of Phlegmasia Alba 
Dolens. — Gaz. des Hop. 100. 

49. Atthill, L., on a Case of Puerperal Mania. — Dubl. Jour. LI. Aug. 

50. Lebert, Puerperal Chlo7'osis with Fatal Result. — Wien. Med. 
Wochenschr. August 21. 

51. Caulson, W., on Secondary Affections of the Joints in Puerperal 
Women. — Brit. Jour. March. — Amer. Med.-Chirurg. Review. May. 

52. Clemens, Th., on Color-Rlindness during Pregnancy; with Re- 
marks. — Arch. f. phys. Heilk. H. I. 

53. Ulrich, on a Case of Vomitus Gravidarum; Death in the ith Month 
of Pregnancy. — Mon. Schr. f. Geburtsk. February. 

54. Buckingham, Vomiting and Purpura during Pregnancy. — Boston 
Jour. LIX. 5. Sept. 2. 

The most important event of the year was the discussion on 
puerperal fever in the Paris Academy of Medicine. The incident 
which called forth the discussion was of a trifling nature. Dr. 
Guerard lost a patient from puerperal fever, and this accident induc- 
ed him to bring the subject of puerperal fever before the Academy. 
The first orator moved in very limited circles, which growing larger 
and larger gave origin to some of the most interesting and elaborate 
communications on record. The old guard took the lead in the 
battle, the fight was hot and spirited, agitating this learned body 
from centre to circumference. The great attraction of these academ- 
ical discussions is due to the fact, that the members of this Society 
do not confine their study to their respective speciality, but are able 



238 

to speak on any subject of general interest, while, on the other hand, 
the great oratorical capacities with which almost every member of 
the French Academy is gifted, renders these speeches often more 
lengthy than desired. With regard to the final result of the discus- 
sion before us, we must say that science has been very little ad- 
vanced by it, either from a theoretical or a practical point of view. 
The ideas as to the nature of the disease are just as unsettled as 
they were before, the only point upon which all agreed being the in- 
efficiency of all the means hitherto proposed for treating the fever. 
The spirit exhibited in this centre of medical science spread all over 
the country, and roused the medical press, and called forth a more 
or less important treatise from the pen of almost every prominent 
member of the French profession. 

The points offered by Dr. Guerard, on which the discussion centered, 
are comprised under three heads — 1. Nature of the disease. 2. Mode 
of propagation. 3. Treatment. 

1. What part do the local inflammations have in the production of 
the fever ? It is a fact that in many cases of puerperal fever no 
local lesions whatever are to be found after death (observations of 
Tonneld, Voillemier, Bourdon) ; while in those cases of a " foudroyant" 
type there is no chance for the development of any local disease. 
The puerperal fever begins, in many instances, during confinement 
or soon afterwards, while the first symptoms of local inflammations 
always occur after a certain length of time, and these lesions vary 
in number and intensity following the peculiar nature of each 
epidemic. Therefore, these local inflammations are of a secondary 
order, and the consequence of a general cause. Is the cause of puer- 
peral fever a purulent infection ? The starting-point of purulent in- 
fection is the presence of pus in the veins and lymphatics. But, in 
many cases of puerperal fever, neither phlebitis nor lymphangoites 
are met with ; and, tm the other hand, a phlebitis may occur after 
confinement without producing puerperal fever, and several persons 
have injected pus into the veins, but failed to produce serious 
lesions. Therefore, puerperal fever is not due to purulent infection. 
The blood of every pregnant or parturient woman has a particular 
constitution, which is liable to generate specific virus in mother and 
child, under favorable circumstances, the symptoms of which are 
comprised under the name of puerperal fever. 2. Mode of propaga- 
tion. There is a sporadic and an epidemic form under which the 
fever manifests itself. One way of propagation is by infection, 
because, as soon as an epidemic arises in an hospital, it has been 
found a good plan to shut it up ; because women near their full term 
leaving the city when an epidemic rages, are benefited by this 
change ; because women living for a length of time in an infected 
place are less liable to the disease than those who have recently en- 
tered it. Those facts reported by Dr. Depaul seem to establish the 
fact, that puerperal fever is transmissible by some kind of inocula- 
tion, or by the emanations coming from the patients. 3. Treatment. 
The chief remedies proposed for the cure of puerperal fever are — 1. 
Antiphlogistics. 2. Narcotics. 3. Sulphate of quinine. 4. Ipecacu- 
anha and mercurial ointment. At the "beginning of the disease, local 



239 

antiphlogistics have been used successfully in some forms. The 
experiments with narcotics are not numerous enough to decide on 
their value. The opium seemed to have a good effect in some 
(sporadic) cases, in the dose of 20 or 25 centigrammes pro die. 
[This is a remarkably small dose. — E. N.] Drs. Beau and Lendet 
have used, and, as it seems, successfully, the sulphate of quinine. 
Ipecacuanha, used even now extensively, has been employed very 
successfully (Tonneld) for some months, while after this time not 
one patient was benefited by emetics. Therefore, we have no specific 
remedy for puerperal fever, and different epidemics demand a differ- 
ent treatment. 

After thus opening the discussion en feu de tirailleur, Dr. Depaul 
prepares to make the first charge. There is, no doubt, a peculiar 
disease that must be called puerperal fever, the seat of which is 
primitively in the blood. The disease is of an epidemic nature, it 
developes and behaves like most of other general diseases (typhus, 
cholera, etc.). It spreads most extensively in places crowded with 
women in childbed. Its outbreak is often preceded by other general 
diseases, such as diphteritis, purulent ophtalmia, erysipelas, etc. 
The disease called puerperal fever at times seizes upon persons who 
are not in the puerperal state. During violent epidemics it happens 
that pregnant women are taken, and die from it even before labor 
had commenced. In other instances the poison particular to this 
disease developes during labor or shortly afterwards, and death fol- 
lows in a few hours. The foetus, while in the womb, may be affected 
by this poison, and at times some of the local alterations belonging 
to puerperal fever are found on its body. Sometimes all women who 
are delivered on the same day are stricken with the disease, while 
those who are confined the following day escape, though they are 
apparently under the same condition. 

In almost every serious epidemic, some cases may be observed 
where no local lesion whatever is present. Dr. Depaul recollects 
one case of this kind, where the patient died 15 days after the begin- 
ning of the affection — some alterations in the blood were all that 
could be detected. In some epidemics the inflammatory affections of 
the peritoneum prevail, in others presence of pus in the lymphatics 
or pleuritis, meningitis, arthritis, etc., are prevalent. 

The epidemic nature of the disease cannot be doubted ; in some 
places it recurs every year. From the statistics of the Maternite de 
Paris, it appears that from 13,826 women confined during 5 years, 
230 died from puerperal fever, i. e., 1 out of 60. This is a small 
number compared to the average u umber of deaths of the other 
obstetric hospitals. Of 2,418 women who were delivered at the 
Maternite* during 1856, 114 died from puerperal fever, i. e., 1 out of 
19, while in the city (12me. arrondissement) only 1 out of 322 died 
from puerperal fever in the same year, which proves that the mor- 
tality in the city was seventeen times less than in the Maternite* and 
Clinique. Of all the obstetrical hospitals the Hopital St. Louis 
shows the smallest number of deaths, even a smaller than the 12me. 
arrondissement. The explanation of this fact may be taken from the 
small number of confinements, or from the disposition of the single 



240 

wards, the obstetric department of this hospital being exposed to 
the west and east. It contains two large rooms, each of 8 beds, and 
8 small rooms, with one single bed. The Hopital Lareboisiere, on 
the other hand, shows a large amount of fatal cases, though it has an 
excellent situation and a favorable disposition inside. From 31,661 
women in the different hospitals, 644 died from puerperal fever, i. e., 
1 out of 48 women. Puerperal fever, like all general diseases, 
becomes contagious under certain conditions. Two cases are record- 
ed where the nurses took the disease from women affected with puer- 
peral fever. At times it happens that all women delivered in certain 
beds die one after another from puerperal fever, while those lying 
beneath them in other beds escape. Two observations are reported 
by Dr. Depaul, which seem to show that the disease might be trans- 
ported from one to another place by healthy individuals after fre- 
quent intercourse with the sick. Another fact speaking in favor of 
the essentiality of the disease is the altered condition of the blood, 
as observed by Depaul, Virchow, Scanzoni, Lehmann. 

With regard to diagnosis of puerperal fever, it may be said that 
it has no pathognomonic symptom of itself, and it is rather the coin- 
cidence of several symptoms which characterizes the disease. The 
fever generally appears 48 or 50 hours after delivery — seldom after 
the eighth day. One of the most constant symptoms is a chill at the 
beginning, which in most cases appears only once, or recurs after 
24 or 36 hours, while sometimes it repeats at regular intervals, thus 
simulating intermittent fever. After this the pulse rises generally 
up to 140 or 160 strokes in a minute. The temperature of the skin 
is not increased in a very remarkable degree, while it is generally 
dry, the cold sweat making its appearance towards the fatal end. 
The trouble in the respiration is very significant, it being short, 
hasty, and intermixed with deep inspirations. The change of expres- 
sion in the features has been observed by most physicians to be per- 
ceptible from the beginning of the disease. With this are combined 
certain intellectual troubles, the patients seem to awake from a 
slumber when accosted, and speak often with a peculiar trembling 
voice. In some of the most unfavorable cases, pains around the 
joints or in different muscles are observed, not unfrequently combin- 
ed with a red hue of the skin, a disposition which unavoidably leads 
to a fatal result. Diarrhoea is seldom absent ; abdominal pains, in 
some instances, very violent, in others wanting. To distinguish 
puerperal fever from purulent infection, the following points have to 
be considered : purulent infection is not known to set in before the 
8th or 10th day ; the chills are generally multiple, followed from the 
beginning by Copious, viscous sweats ; they repeat for several days 
in irregular intervals ; the skin takes a dirty icteric appearance ; 
the urine has a peculiar stench ; there is a great tendency towards 
formation of abscess in the areolar tissue or the cavity of the joints ; 
the disease lasts at least 8 or 10 daj's, often many weeks. Another 
affection akin to puerperal fever is the putrid infection, which 
depends from different circumstances ; at times it arises from decom- 
posed clots of blood retained in the vagina or uterus ; in other in- 
stances retained pieces of the membranes or of the after-birth are the 



241 

cause of it, or it comes from the dead foetus itself. In putrid infec- 
tion the chills are not severe, the tongue becomes dry and furred, 
the expression terrified ; when this condition has lasted for awhile it 
changes to a hectic fever, with diarrhoea. The typhoid fever is 
easily distinguished from this affection. With regard to treatment, 
the right way has yet to be found ; we have no remedy which can 
be relied upon. The very few cases (2 or 3 out of several hundreds) 
which Dr. Depaul saved, were treated with mercury, although in the 
greatest number of cases this remedy had not the least influence, 
and not one case of genuine puerperal fever has been benefited by 
quinine. With regard to veratrum viride, Dr. Depaul suggests that 
this remedy will not sustain for a length of time the sanitary in- 
fluence attributed to it by Dr. Barker. As a prophylactic remedy, 
the sulphate of quinine has not rendered any better services to Dr. 
Depaul, though other authors seem to have derived considerable 
benefit from its administration. Up to the present time, no prophy- 
lactic measure has been found which was apt to influence the pro- 
gress of the disease. The only way to diminish the number of 
victims would be, to abolish all lying-in hospitals, and have the 
women delivered at their own residences. 

3. Dr. Beau defended his medication (sulphate of quinine in high 
doses) against Dr. Depaul's aggressions, who asserted that the cases 
cured by Dr. Beau were not exactly what is called puerperal fever. 
Dr. Beau professes his belief that puerperal fever is a symptom con- 
nected with peritonitis, or some other inflammation. The existence 
of a so-called inflammatory diathesis cannot be doubted. This same 
diathesis exists in puerperal women, and this is the pathological in- 
fluence to which must be attributed the production of the manifold 
local inflammations during childbed. The symptoms of this condition 
vary with the different local affections. Besides this diathesis, there 
exists an epidemic influence, till now perfectly unknown in its 
nature ; both combined produce the different phlegmasies of the 
puerperal state, and of these the peritonitis is met with in 19 out of 
20 fatal cases. Follows a description of the peritonitis, of which he 
distinguishes the supra-umbilical (general) and infra-umbilical form ; 
the former alone is sufficient to produce, like general pneumonia, all 
the disastrous symptoms attributed to puerperal fever. The inflam- 
mation of the peritoneum depends from a previous general trouble of 
the system ; this is for Dr. Beau the inflammatory disposition, while 
it is for Dr. Depaul and the rest the puerperal fever itself. To give 
further proof of his assertions, Dr. B. goes on to show that puerperal 
peritonitis bears the character of a phlegmatic, and not of an erup- 
tive fever, as claimed by his adversaries. Moreover, there is never 
an eruption .to be found as it is in typhoid and similar affections. 
The typhoid symptoms, as observed occasionally during puerperal 
fever, prove nothing against the theory, many other inflamma- 
tory diseases presenting the same typhoid symptoms. The blood 
has the same qualities as that in other inflammatory diseases, viz., 
increase of fibrine, just the reverse of what is found in eruptive 
fevers. With regard to puerperal fever without local lesions, it 
must be remembered — 1. That these are exceptional cases. 2. That 
16 



242 

the local disease is often unobserved, even after a rigid post-mortem 
examination (two cases reported). 3. It happens that women in 
childbed die from a fever which is by no means of a puerperal char- 
acter, as might be seen at times in a lying-in hospital at a time 
when no puerperal epidemic is prevalent. 4. If the blood of many of 
these so-called puerperal fever patients was to be examined, many 
cases would turn out to belong to the eruptive class. 

It is of greatest importance to begin with the treatment of puer- 
peral peritonitis as soon as possible. First of all, an emetic has to 
be given, consisting of ipecac, 1 grm.; tartar emetic, 10 cgrm.; one- 
half of it to be taken every half hour. This is to remove the bilious 
habit often connected with the fever, and in order to better prepare 
the stomach for the reception of the quinine. The first dose of sul- 
phate of quinine, 1 grm., is given after all nausea has passed over ; 
8 hours after this, 15 cgrm. are given, and the same quantity after 8 
other hours. During the following days, this treatment is continued 
every eighth hour ; as soon as the physiological effects of the quinine, 
drowsiness, deafness, etc., begin to show, all the symptoms of the 
disease lessen in a remarkable degree. This treatment must be con- 
tinued for some time, and if the powder is rejected it must be given 
in another form, in pills, etc. Besides this, a flying vesicatoire may 
be placed upon the most painful spot of the abdomen. The curative 
effects of quinine are restricted to those cases where the peritonitis 
has not reached the superumbilical region ; and it is also of no avail 
when a concretion of blood has formed in the heart. The non-success 
of this remedy in the hands of Dr. Depaul, is explained by the fact 
that his doses were not sufficiently large ; it ought to be given in 
the dose of from 2 to 3 grammes in 24 hours. 

4. Dr. Piobry, after a sketch of the different conditions generally 
comprised under the name of puerperal condition, and a description 
of the peculiarities of the puerperal state, comes to the conclusion 
that puerperal fever is not " une unite 1 morbide" but the reflex of one 
or more of these puerperal phenomena, exaggerated to a real disease. 
And after all, there might be a virus which propagates the fever, 
which, however, spontaneously developes in patients who had no 
communication previously with other puerperal patients. We, there- 
fore, have not to deal with a specific puerperal fever, but with a 
patient suffering from septic uteritis, phlebitis, modified by the pres- 
ence of putrid matters in the womb, metroperitonitis, septic peri- 
tonitis, septicemia, pyaemia, pleuritis, arthritis, retention of foeces 
and gas in the intestines simulating peritonitis, hypsemia, or a con- 
siderable elevation of the intestines and the diaphragma, owing to 
aforesaid circumstances, with difficult respiration, dilatation of the 
heart, pulmonary congestion, accumulation of phlegm in the air- 
tubes, hyposemia and death. By taking this view, the indication 
for treatment is not derived from a disease called puerperal fever, 
but from its elements, and against every one of its elements, as 
pointed out above, the treatment must be directed. In specifying 
the remedies to be applied against every one of the original diseases, 
the author lays great stress upon the necessity of cleansing injections. 
Dr. Piorry has not lost one single patient in the pitie*, from puerperal 



243 

peritonitis, for five years, owing to these injections. Against accu- 
mulation of gases or fasces, cathartic injections and oily frictions in 
the direction of the intestinum crassum, have had a wonderful effect. 

5. Dr. Hervez de Chegoin declares for the specific nature of puer- 
peral fever, it being a disease for itself, which can exist independently 
from any inflammatory affection. There are two varieties of puerpe- 
ral fever ; one a putrid, one a purulent puerperal fever ; putrid or 
purulent infection starting from the uterus being the cause of the 
disease in question. All prophylactic remedies are of no avail be- 
fore we know which form we will have to deal with. After even 
the safest delivery, injections into the womb have to be made when- 
ever we suspect that small particles of the placenta or the mem- 
branes are left behind, or a foetid discharge begins to issue from the 
genitals. But as soon as the putrid infection or puerperal fever is 
established, we have to fulfill three indications, viz.: 1. To remove 
the cause. 2. To neutralize it. 3. To put the organism in a proper 
condition to resist the toxic influence. The remedies for this pur- 
pose are injections, cathartics or sudorifics, antiseptics and tonics. 
In the purulent form, at the beginning, an energetic antiphlogistic 
treatment must be applied. 

6. Dr. Trousseau does not acknowledge a fever peculiar to women 
in childbed, but only a fever peculiar to wounded men and women. 
In the epidemic of 1855, when so many women died from the fever, 
it was very remarkable that an unusually large number of children 
fell under umbilical phlebitis, peritonitis, pleuritis, etc. ; children of 
mothers who were never taken with the disease, besides many chil- 
dren still-born with peritonitis from a healthy mother. The men, 
upon whom operations had been performed in the surgical wards, 
died in great numbers from inflammations of the serous and synovial 
membranes, from putrid fever, as soon as in the adjacent lying-in 
wards the puerperal fever began to develop. The fever appears in 
different forms, as a purulent, a putrid, or a nervous typhus. These 
different affections do not belong exclusively to women in childbed, 
but are observed in the foetus as well as in male patients. In the 
epidemic which Dr. Lorrain has described, 1 or 8 children died in utero 
with pus and false membranes in the peritoneum. In 1842, Dr. 
Trousseau described as puerperal fever of the foetus, certain forms of 
erysipelas, phlebitis, and muguet of new-born children. Also, Dr. 
Lorrain has already pointed out the resemblance of the foetal and 
the puerperal state, comparing the umbilical wound with the denuded 
surface of the womb, and calling the purulent secretion from the 
navel, umbilical lochia. From this point, absorption followed by 
phlebitis is easily established, and these children die from erysipelas, 
putrid inflammations, or diphtheritis. But some women are. taken 
with puerperal fever at the beginning of labor, no Wound being as 
yet established (Tarnier, Dubois, Danyau), and even midwives 
attending fever patients, during (Depaul, Delpech, Danyau, Dubois), 
or even some time after menstruation (Tarnier), have been taken 
with the disease. In women who died from puerperal fever, puru- 
lent metastatic collections have Toeen found in the pleura, in the 
articulations, etc. Dance and Tessier found the same lesions in the 



244 

men who died from traumatic fever. This traumatic fever of women, 
children, and men, has a specific cause ; it is a morbific substance 
which enters the system, finding especially upon wounds a fertile 
soil for development, from whence it is diffused throughout the sys- 
tem. This specific materia does not always originate from the 
female, and does not belong to her exclusively. The only thing that 
makes women in childbed more apt to get this fever, is the peculiar 
condition, by which she is less liable to resist the influence of morbid 
causes. With regard to treatment, not a single remedy has given 
satisfactory results ; a remedy successfully applied to-day in one 
locality, fails to-morrow or in another quarter. 

T. Dr. P. Dubois distinguishes two groups of morbid phenomena in 
puerperal women. In the first instance, the disease begins with a 
chill, followed by fever, flushed cheeks, violent headache, a moist 
whitish or yellow tongue, quick respiration, a moderate pain in the 
lower part of the abdomen, while the womb is painful when touched 
through the flaccid abdominal walls, the secretion of milk is dis- 
turbed. The second form is in some respects similar to the foregoing 
condition ; it has a chill at the beginning, fever, headache, alteration 
of the features and respiration, abdominal pain, suppression of milk ; 
and still the character of all these symptoms differs considerably 
from those of the first order. The chill ■ is more intense, of longer 
duration, and nearer to the time of delivery ; the face, instead of being 
red, is pale and greatly altered, the respiration rapid and oppressive ; 
there is a constant agitation ; the abdominal pain is stronger, and 
taking a larger surface, the abdominal walls are bulged from meteo- 
rismus, and, instead of constipation, diarrhoea is present ; the dis- 
ease is almost always fatal. It is the second form only that comes 
under the head of puerperal fever, while the former affection may 
increase to such a degree that it becomes equivalent to puerperal 
fever in its ultimate results. The only cause of puerperal fever is a 
primitive alteration of the blood, the nature of which is hitherto un- 
known ; neither the theory of purulent nor of putrid infection as a 
cause of the fever are admissible. 

8. Dr. Cruveilhier. — There are two forms of puerperal fever ; a 
benign and a malign form. The former consists of a uterine phle- 
bitis, not surpassing the obliterating or adhesive stage, which is at 
times combined with partial peritonitis ; the other form, or the classic 
puerperal fever, has four striking characters, viz.: 1. Chill at the 
beginning. 2. Peritonitic abdominal pains, before, during, or after 
the chill. 3. Profound alteration of the features. 4. Extreme weak- 
ness, frequency, and softness of the pulse. During the five epidemics 
observed by Dr. Cruveilhier, every kind of treatment was tried, but 
to no avail. In the epidemic of 1832, from 15 women affected with 
the fever, 10 were dead on the fifth day, and the cholera which pre- 
vailed at the same time in Paris, left not by far an impression upon 
the orator's mind similar to that of puerperal fever, which he used to 
call puerperal typhus. The only remedy that could have an influ- 
ence upon this dreadful scourge, is the closing up of all lying-in hos- 
pitals, and have the women attended at their residences. It is a 
contagious miasmatic disease, like the hospital gangrene. With 



245 

regard to the pathological anatomy of puerperal fever, it is astonish- 
ing how little time is wanted for the production of pus in this disease. 
Dr. Cruveilhier has found pus in the peritoneum 24 hours after the 
invasion of the disease. The tendency to formation of pus is the 
great feature of puerperal fever. After peritonitis, purulent subper- 
itoneal cellulitis is most frequently met with. The second chief 
lesion owing to puerperal fever, is purulent lymphangitis. This is 
specific to puerperal fever, and met with in no other disease. The 
presence of pus in the uterine veins is by no means as often found as 
pus in the lymphatics. In all, or almost all, post-mortem examina- 
tions performed from June, 1830, to September, 1832, purulent 
lymphangitis was found, while only 8 cases of purulent phlebitis 
presented themselves ; and while purulent phlebitis is often observed 
unconnected with peritonitis, the lymphangitis is almost always found 
in connection with peritonitis or cellulitis. The metastatic abscesses 
in liver, lungs, etc., are always the consequence of phlebitis, but 
never originating from lymphangitis, as the interposition of the 
lymphatic glands prevents the spreading of purulent infection. ( It is 
easy to distinguish both lymphangitis and phlebitis from each other ; 
the purulent veins always exhibit traces of inflammation, their walls 
are thick, brittle, injected all over their external tunic, adherent to 
the adjoining tissues, surrounded by a pseudo-membranous layer, or 
containing fragments of coagulated blood. The lymphatics have very 
thin and generally transparent walls, and are in no connection with the 
neighborhood ; the pus they contain is of a very pure quality, looking 
like milk, and in tracing their course they are found to run towards 
the lymphatic glands, which are injected with pus. Besides these 
chief characters of puerperal fever (peritonitis and lymphangitis) 
the third in frequency is uterine phlebitis, the fourth, purulent phle- 
bitis. With regard to the question whether the fever is the primitive 
element, or the local inflammations, Dr. Cruveilhier proposes that 
puerperal fever is fever and inflammation at once, both being the 
consequence of one common cause, viz.: miasmatic infection. The 
best name to express the nature of puerperal fever would be : trau- 
matic fever of women in childbed, as a recently delivered woman may 
be compared exactly to a person upon whom a great surgical opera- 
tion has been performed. 

9. Dr. Danyau. — Puerperal fever is a disease of miasmatic origin, 
which entering and poisoning the blood, renders it liable to^produce 
in most cases, very rapid inflammatory deposits. It is a remarkable 
fact, that the epidemic spreads at times over whole cities, countries, 
and even continents. In 1819, for instance, the fever was observed 
at the same time at Vienna, Prague, Dresden, Wlirzburg, Bamberg, 
Ansbach, Dillingen, in many towns of Italy, at Lyons, Paris, Dublin, 
Glasgow, Sterling, Stockholm, Petersburg. Some of these epidemics 
even extended to the domestic animals, to the bitches, for instance, 
during the epidemic of 1787 and 1788, at London ; at Edinburgh, in 
1821 ; at the same time cows were affected in several parts of Scot- 
land, and hens in the neighborhood of Prague, in the epidemic of 
1835. To prove the miasmatic character of the disease, Dr. Danyau 
reports several cases where children died shortly after confinement, 



246 

from mothers who were taken with puerperal fever. With regard to 
the question of transmissibility of the miasma from one person to 
•mother, Dr. Danyau reports a great number of facts, which seem to 
show that an accoucheur, who attended a lady stricken with the 
fever, is apt to propagate the disease to other women in childbed. 
Dr. Scmmelweis' theory of cadaveric infection is not considered 
as established beyond doubt, still it would be unsafe to attend a 
woman in confinement immediately after performing a post-mortem 
examination, without taking such precautions as may seem efficient 
to lessen the probability of transportation of putrid effluvia. The 
sulphate , of quinine has been tried by Dr. Danyau, but not fulfilled 
what was expected from it. Dr. Piddagnel's phophylactic remedy 
(sulphate of quinine and carbonate of iron) was tried in three hundred 
women, near their full term, and the result was, that the proportion 
of severe cases and deaths was smaller among the women who were 
treated in this way, compared to those who underwent no prophylac- 
tic treatment, while on the other hand, the value of this remedy be- 
comes ve'ry questionable, when eight women out of one hundred 
exhibited serious puerperal diseases, and five died from three hun- 
dred women confined in a hospital, which at the time of the experi- 
ment was not subjected to the epidemic. The only effective remedy 
would be, perhaps, the suppression of all lying-in hospitals, but in 
doing so, the great advantage for instruction would be lost, a host of 
homeless women would be delivered under equally disadvantageous 
circumstances, and very likely the fever would spread more exten- 
sively in the cities than it has done before. Instead of abolishing 
the hospitals entirely, it would be better to increase their number, 
and use the different wards in rotation ; airing, fumigating, and 
whitewashing the rooms as they are emptied. 

10. Dr. Cazeaux insists upon the alteration of the blood in puer- 
peral women, and its influence upon the production of the disease in 
question, the inflammatory character of which cannot be doubted. 
He does not admit a puerperal fever as coming from a specific out- 
side influence. It is the intense alteration of the blood that renders 
inflammations of women in childbed so disastrous. All diseases tak- 
ing women in childbed take a very severe course, such as scarlatina, 
smallpox, pneumonia, pleuritis, etc. ; why should not inflammations^ 
peritonitis, lymphangitis, be more disastrous with women in child- 
bed th^n otherwise. This propensity to disastrous diseases, nat- 
urally increases at the time an epidemic prevails, as is the case with 
bronchitis, pneumonia, etc., and it is not necessary to acknowledge a 
specific influence producing puerperal fever. With regard to treat- 
ment, Dr. Cazeaux asserts, that he never saw a woman die who 
could be salivated by small doses of calomel, but it is difficult to 
bring on salivation very quickly. 

11. Dr. Bouillaud declares for the non-essentiality of puerperal 
fever ; he does not consider it as a fever sui generis ; it is a traumatic 
fever, modified by a peculiar condition of the blood of women in child- 
bed. The puerperal state is a kind of intermediate condition be- 
tween health and disease (un dtat semi-pathologique) ; its likeness 
with the condition of wounded persons is so generally admitted, that 



247 

no serious contradiction has been sustained on this point ; the puer- 
peral state constitutes a morbid predisposition in general, and an 
evident predisposition to certain local and general affections, viz., 
inflammations and feverish reaction ; inflammations developing dur- 
ing the puerperal state, have a marked tendency to suppuration ; 
the puerperal state does not only influence the generative organs, 
but has a bearing upon the entire system ; therefore the puerperal 
state is an aggravating circumstance in all inflammatory or other 
diseases arising during its existence. From these considerations, it is 
evident that the word puerperal may be applied for those local inflam- 
mations with a fever which seize upon the puerperal woman ; it repre- 
sents the modifications which the puerperal state contributes to 
these affections. Dr. Bouillaud proceeds to give a historical sketch 
of the previous discussions on puerperal fever in*France, and con- 
siders some of the weak points of the speeches of his adversaries, 
especially of Drs. Trousseau and P. Dubois, and shows that puerperal 
fever is not a fever sui generis, because neither its seat, nor cause, 
symptoms, evolution, course, treatment, mortality, or denomination, 
have anything peculiar. The purulent and putrid infection of the 
blood are sufficient to explain the general phenomena which consti- 
tute puerperal fever. 

12. Dr. Dubois, in a second communication, subjects the facts 
called forth to prove the possibility of transmission by contagion, to 
a rigid examination, and comes to the conclusion, that this way of 
propagation is far from being established beyond doubt. He be- 
lieves that the conditions necessary for the development of puerperal 
fever exist already, before labor begins, in a certain number of sub- 
jects, a fact which can not be explained either by putrid and puru- 
lent infection, or by the so-called uterine tranmatisme. With regard 
to treatment, nothing can be done against the veritable puerperal 
fever (Dubois's second class, Beau's peritonitis supra-umbilicalis), 
while its milder form may be overcome by different remedies, such 
as quinine, ipecac, tartar emetic, bleeding, etc. 

13. Dr. Piorry, in a second communication, insists upon the fact, 
that in a great number of cases the decaying contents of the uterus, 
and the putrid infection of the blood from this source, constitute the 
so-called puerperal fever, and he thinks that the discussion in the 
Academy is only a fight about words, as the different speakers agree, 
without knowing it themselves, upon the nature of the disease. He 
proposes the name of septicemia, as best designating the sources of 
the disease, viz., from putrid infection from the uterus, and by the 
respiration of an atmosphere pregnant with septic particles. The 
septicemia originates as well from a wound cut with a scalpel, con- 
taining cadareric blood, as from «, bed-sore in putrifaction, and from 
a place overcrowded with patients. The admission of this septicemia 
explains the putrid accidents, as observed in men, the foetus, and 
wounded persons during a puerperal epidemic. 

14. Dr. Dubois, in a third communication, expresses his belief, that 
the suppression of the lying-in hospital would not effect a consider- 
able change in the rise and spreading of the disease, as it is well 
known that very often the epidemics in hospitals are preceded by 



248 

severe outside cases, and epidemics in even the smallest cities have 
been observed of a more disastrous character than those seizing upon 
hospitals. The only justifiable means to prevent the disastrous 
spreading of the disease, consists in a profound modification of the 
present lying-in asylums. In the neighborhood of the present build- 
ings, new ones ought to be erected fit to receive six or eight hundred 
women every year. These should be divided into two principal sec- 
tions of equal capacity, each one of these sections to be subdivided 
into different rooms, each capable of receiving ten beds, which must be 
separated from each other by a larger space than is generally allowed 
in ordinary hospitals. To this construction, the best mode of ventila- 
tion is to be added. The small rooms ought to be used in rotation, 
each of them to be thoroughly aired and cleansed after having been 
in use for a length of time. At a time when an epidemic begins to 
make its appearance, the hospital affected ought to be closed entirely, 
and the women attended at their homes. 

15. Dr. Trousseau, in a second communication, resumes his views 
under the folio wing heads : 1. The puerperal fever does not differ from 
the so-called chirurgical fever (" purulente, de resorption"); 2. In 
the great majority of cases, the placentar wound occasions the dis- 
ease ; 3. Its cause exists in a specific principle, only known in its 
effects ; 4. It is not impossible, that even a person not wounded, 
might be affected by the disease during an epidemic. A healthy 
woman coming from the country to Paris to be delivered in a few 
hours, is taken there with a violent fever and dies in a few days : 
a disposition in the blood is not required ; she catches the disease 
as she would the cholera, the yellow fever, or the intermittent 
fever. In puerperal fever the general affection does not exist pre- 
vious to the local lesions, except in a few very rare instances, nor 
is the vascular inflammation of that great importance imputed to 
it. Phlebitis exists in almost every case of delivery ; it is to be 
found with every wound ; the adhesion of the coagulated blood with 
the walls of the vessels, is a sign of present or past inflammation. 
Phlebitides of great extension, spreading from the foot up to the 
venae iliacaa, the phegmasia alba doleus, make very often not the 
least impression upon the system, producing scarcely any febrile re- 
action. Why, then, should phlebitis be of such vast importance in 
the puerperal state ? Some other specific influence must be added 
to the phlebitis, in order to render its presence so very disastrous as 
it is in puerperal fever. Moreover, it has been demonstrated that 
the pus-globules are too large to pass through the capillary vessels ; 
even the presence of laudable pus in the blood does not make any 
considerable impression upon the system, a fact well proven by ex- 
periments, while putrid particles injected into the blood produce 
violent general accidents. Nor does the serum of pus, if absorbed,"as 
it happens in tuberculous patients, produce symptoms similar to 
puerperal fever, but only what is called colliquative symptoms. At 
times it happens that the most insignificant operation, as the de- 
pression of a cataract, the opening of an abscess, leads to traumatic 
typhus and death ; there must be a specific cause to produce these 
fatal effects. Why is it that women outside the hospital, where they 



249 

live in filth and dirt, in the most unhealthy locations, do not die from this 
fever ? Why is it that at times when the hospitals are over-crowded, 
not a case of fever is observed, when at other seasons they die by 
the dozen, although the number of women in confinement is compara- 
tively small ? Dr. Trousseau firmly believes that the contagious mias- 
ma of traumatic and puerperal typhus, remains in a latent state, in 
the surgical and obstetrical wards, rising to activity at certain days 
under certain unknown conditions. If the hydrophobia proceeds 
from an infecting bite, the syphilis from an infecting ulceration, then 
the traumatic fever must proceed from an infecting wound, and the 
puerperal fever from an infecting placentar wound. In some very 
rare instances, the infection in puerperal fever might be established 
" d'emblee," i. e., not entering through the wound, but throjugh the 
lungs or skin. 

16. Dr. Velpeau read some portions of his former articles on 
puerperal fever, written about thirty years ago, thus showing 
that all that has been said pro and contra is not much more 
than a repetition of former ideas. For his own part, Dr. Velpeau 
has not changed his mind since the time of his first writings. 
Puerperal fever is a peritonitis, a lymphangitis, a phlebitis, a puru- 
lent or putrid infection, modified by the puerperal state. The dis- 
ease is a specific disease, inasmuch as every disease has a more or 
less specific character. With regard to treatment, Dr. Velpeau ad- 
heres to his old propositions, viz. : bleeding, calomel in small doses, 
mercurial inunctions (10 grms. every two hours), and afterwards 
an enormous flying vesicatoire upon the abdomen. 

IT. Dr. Guerin considers the more or less perfect contraction of 
the womb after confinement in connection with puerperal fever. In 
ordinary cases the fundus uteri is situated in a line with the umbili- 
cus immediately after delivery, while, during the following three or 
four days, it gradually contracts so that its vertex sinks down as far 
as the symphysis pubis. In puerperal fever patients, the fundus not 
only remains near the umbilicus during the entire existence of the 
disease, but the womb even contracts or swells up according to the 
changes of the disease for good or evil. The consequence of this 
flaccid state of the womb is the permanent existence of the cavity in 
the uterus, which is filled with clots of blood or the lochial secretion ; 
the placentar wound is extended, the vascular orifices remain gap- 
ing, and a permanent contact with the atmosphere is established. 
Owing to this, the uterine wound instead of being closed and healing, 
quasi per primam, is exposed to the air and suppurates ; the contents 
of the uterus decay by the touch of the atmosphere, and the womb is 
filled with a fluid mass in a state of putrifaction. Hence the fatal conse- 
quences : chills, fever, poisoning of the blood, secondary inflamma- 
tions. This condition of the uterine wound alone would not be suffi- 
cient to produce the puerperal fever ; the consequences of this abnor- 
mal condition are complicated and influenced by the peculiar dispo- 
sition of women in childbed, by the condition of the air in which the 
patient is placed, and by many other casualties. The liquids con- 
tained in the womb do not only infect the blood by resorption, but 
pass into the abdominal cavity by way of the tubes, which are often 



250 

found filled with pus, without offering themselves the slightest 
trace of inflammation. This explains the fact that the peritoneal 
exudation has its principal seat upon the superior layer of the intes- 
tines. The weight of the atmosphere, in free communication with the 
womb, presses the liquids contained in the womb through the tubes 
to counterbalance the diminished intraperitoneal pressure. For 
treatment Dr. Guerin proposes the ergot of rye to be given immedi- 
ately after confinement, and those remedies which apply to every 
single secondary symptom as it makes its appearance. 

18. Dr. Cazeaux, in a second communication, answers to some 
objections raised against his theories by some of the former speak- 
ers, and endeavors to demonstrate the incorrectness of Dr. Guerin's 
views. 

19. Dr. Depaul, in a second communication, defends himself against 
the aggressions of several orators, and goes on to show that Dr. 
Guerin's new theory of puerperal fever is absurd and unworthy of a man 
of his standing. He continues to defend his opinion, considering puer- 
peral fever a specific disease. He points to the fact that the disease 
in question makes its appearance in an epidemical form, as a general 
rule, analogous to all specific diseases, cholera, typhus, typhoid 
fever, and adds another example to prove the contagiosity of the 
disease. In all post-mortem examinations the same alteration of the 
blood is found and can be easily demonstrated, this being in some 
instances the only pathologico-anatomical result, while the local 
lesions are of a very varying character. The principal character of 
this alteration is a change in the blood-globules, which have become 
unfit for hematosis, not being reddened any more by the influence of 
oxygen (Vogel). Hence the great anxiety observed in puerperal 
fever patients, and the great hindrance in respiration. Dr. Depaul 
asserts that he, for himself, has already met with 15 cases where 
no local lesions could be found, although the post-mortems were made 
with the greatest care possible. Another fact worth mentioning, is 
the multiplicity of local lesions and their peculiar character, a puer- 
peral peritonitis, offering a very different aspect from a simple or 
traumatic peritonitis. The only point of comparison of purulent in- 
fection with puerperal fever, is the fatal termination. It is wrong to 
find analogies between the inner surface of the womb after the delivery, 
and an artificial wound. Where is the pathological condition, where 
the divided skin, muscles, nerves, bones and arteries ? Very justly 
Dr. Depaul remarks, that there is no such thing as milk fever ; where- 
ever a woman has chills or is feverish, there is some pathological 
influence present, which we have to find out. The putrid infection 
is equally different from puerperal fever in its symptoms and cause, 
which may appear in a chronic or an acute form ; it is never connect- 
ed with a peritonitis, as is puerperal fever. Neither Dr. Beau's quinine, 
nor Dr. Velpeau's large blisters, have an influence upon the real puer- 
peral fever ; the very few cases cured were those treated with mer- 
cury. In conclusion, Dr. Depaul repeats his conviction, that the only 
justified and effective prophylactic remedy is the closing of lying-in 
hospitals. In 1831 a Society was formed under the name of Socidte" 
Mddicale d'Accouchment. From this time to 1841, 1,258 poor women 



251 

were attended at their homes, and what was the result, not one 
woman died, while at " La Clinique " 22 died out of 623. 

20. Dr. Gderin, in refuting the attacks of Drs. Cazeau and Depaul, 
says that he considered the want of retraction of the womb only as the 
local cause of all the many secondary evolutions of puerperal fever, 
admitting another influence which produced this permanent swelling 
of the uterus. To prove his theory of migration of pus into the peri- 
toneal cavity through the tubes, Dr. Guerin mentions several experi- 
ments of his own, demonstrating that the peritoneal cavity may con- 
tain a quantity of air in certain conditions, and quotes from Dr. 
Behier's and Dr. Tacquemier's works on peritonitis, observations con- 
firmatory of his own views. 

21. Dr. Beau, in a second communication, insists upon the inflam- 
matory nature of puerperal fever, of which the peritonitis is tfte 
principal character. Phlebitis is often connected with peritonitis; 
when found alone, it is a phlebitis, and not a case of puerperal fever. 
With regard to treatment, Dr. Beau insists upon the early administra- 
tion of the quinine ; it must be given at the very first symptoms of the 
fever. During an epidemic, the resident physician must watch the 
delivered women, and begin the treatment at the very inset of the 
disease. 

22. Dr. Danyau, in a second communication, reports the experience of 
an intelligent midwife, a former pupil of his, with regard to the famous 
12me. arrondissement, the average number of deaths of which com- 
munity Dr. Tamier reports to be 1 out of 322 delivered women during 
1856. At the beginning of 1834, a very disastrous epidemic prevailed 
in this district, and during 5 weeks in February and March, out of 35 
women, 20 were taken sick with the fever, and from these 20 women 
19 died from puerperal fever, most of them a few days after delivery. 

The great diversity of opinions expressed in the Academy rendered 
it a difficult task for the last orator, M. Guerard, to give a resume* 
of the entire discussion. First of all, M. Gudrard rejects the opinion 
pronounced by some of the speakers, that the inner surface of the 
uterus, after delivery, was akin to a wound after a surgical operation. 
The act of placentar detachment is unconnected with any lesion of 
continuity, and the secretion of the placentar surface is not pus, but 
an albuminous fluid ; a purulent discharge from this place is only 
observed in those cases where a superficial inflammation of the 
uterine tissue existed in the neighborhood of the insertion 6f the 
placenta. The great variety of opinions in general may be caused 
by the circumstance that some of the orators had very ample oc- 
casion to study the disease, while to others only a comparatively 
small field of observation was allowed. Among the former are Depaul, 
Dubois and Danyau, all of whom agree as to the principal points 
involved in the question. Finally, the varying characters of the dif- 
ferent epidemics may partly account for the diversity of opinions on 
the nature of the fever. Depaul's, Dubois', and Danyau's views, are 
comprised in the following theses : Women in childbed are exposed 
to different diseases, but the name of " puerperal " disease belongs 
only to those affections which develop under the specific influence of 
the puerperal state. The true nature of puerperal fever is character- 



252 

ized : 1. By the time of invasion (in the first 4 or 5 days, and gener- 
ally in the 48th or 50th hour after delivery, very seldom after the 8th 
day). 2. By the succession and quality of the symptoms. 3. By its 
anatomical character, consisting of a specific alteration of the blood, 
with inclination to rapid formation of pus. 4. By its transmissibility, 
by infection, perhaps by contagion, and direct inoculation. Most of 
the speakers considered the epidemic influence, and the over-crowded 
state of lying-in hospitals, as the principal cause of the eruption of 
the fever ; but these coincidences are often wanted, while the course 
and malignity of the disease are the same. Almost all agree as to 
the curative treatement ; our art is powerless, and the right way has 
yet to be detected. The principal remedies are the opium, the quinine, 
and the veratrum viride ; the latter, recommended, by Dr. Barker of 
New York, has not been tested in Europe. The opium has been very 
successfully employed by Dr. Faye of Christiania, in 1849, while in 
other epidemics it seemed to have no influence whatever. The use 
of quinine, principally advocated by M. Beau, was useless in the 
hands of others. Therefore Depaul and Cruveilhier moved to abolish 
the larger lying-in hospitals, and supplant them by smaller ones with 
12, 16 or 20 beds. This procedure Dr. Danyau believed to be injur- 
ious for the education of young physcians and midwives, and he there- 
fore proposed to retain the hospitals existing, and modify their con- 
struction. 

The discussion of the New York Academy of Medicine opened in 
1857, and closed this year. It is void of that brilliancy which is pe- 
culiar to French orations ; it is void of that vast amount of experience 
collected for decenniums in French hospitals, and still, to say the 
least, it is equally important. The orators were few in number, but 
all that was said was well supported by a stringent logic and 
a sound experience. The discussion has brought forward in bold 
relief two remedies, which are at least worthy a further trial, and 
this is a decided ^advantage over the results of the French discussion, 
which has radically destroyed what little hope was left for one or the 
other therapeutical means to battle against this scourge of humanity. 

The subject of puerperal fever was brought up for discussion in 
the New York Academy of Medicine by Dr. John W. Francis. He 
admits its inflammatory character, and is not willing that this dis- 
order should be restricted in its seat to inflammation of the peritoneal 
lining, thus nosologically denominating the disorder " puerperal 
peritonitis." Dr. Francis is satisfied of its contagious nature from 
the authority of Gordon, and from what he has seen both abroad and 
at home. 

Dr. Joseph M. Smith, after some preliminary remarks on the con- 
tested points regarding puerperal fever, says, that in rejecting the 
opinion that puerperal fever is a disease sui generis, we must also 
reject the idea of its propagation by a specific contagion. That the 
disease is communicable there is no doubt ; but it is through the 
agency of a poison generated in a mode totally different from that 
peculiar to small-pox and measles. Prof. Smith then proceeded to 
consider the special etiology of puerperal fever. 

The conclusions at which Prof. Smith arrived, are, that puerperal 



253 

fever sometimes arises from the noxious air generated from the foul 
discharges of puerperal women in crowded and ill-ventilated lying-in 
hospitals ; sometimes from the emanations of patients laboring under 
typhus fever, erysipelas, and gangrenous diseases ; sometimes from 
the emanations from the human body dissected after death ; and 
sometimes from the absorption of putrescent matters lodged in the 
uterus and vagina after parturition. It would appear, also, from 
this inquiry, that the miasms of typhus, erysipelas, and puerperal 
fever are severally capable of producing any one, or all, of these dis- 
eases ; and that they may attach themselves to the persons and 
clothing of mid-wives and physicians, and thus be transported from 
these sources, to the chambers of lying-in women. The more ordi- 
nary form of disease, induced by the febrific effluvia in question, is 
typhus and its modification, typhoid fever ; while puerperal fever, 
and hospital erysipelas, are but varieties of that disease, taking their 
forms from the peculiar predisposing conditions of system. 

The following facts are important : 1. Let the physician take 
care. 2. When it breaks out in a hospital, thorough resort to disin- 
fecting agents and ventilation, and dispersion of patients is necessary. 

Prof. Clark concurs with Drs. Francis and Smith in regard to the 
communicability of puerperal fever. With regard to its connection 
with typhus, it seems that there are no fixed relations between these 
diseases. I am aware, he says, that puerperal women have been 
placed in beds near those who have had typhus fever, and have died 
of puerperal fever ; but unless these cases are adduced in sufficient 
number to balance the cases on the other side, they may be but coin- 
cidents. No relation has been established between the typhus and 
puerperal fevers, as far as the City Inspector's reports are concerned. 
Prof. Clark here gave a statistical review of deaths from puerperal 
disease and from typhus fever, from 1830 to 1853, from which it 
appeared that the numbers somewhat increase together ; but the 
proportions in which they increase and diminish, showed very few 
analogies between the two diseases. The relation of puerperal fever 
to erysipelas, at Bellevue, has long been remarked. My impression 
is that there is a relation between the two ; this is the prevailing 
opinion there. A few days ago, when the puerperal fever broke out 
there, it was ascertained that erysipelas was prevailing to some 
extent in the surgical wards. 

In looking over the City Inspector's report of deaths for fifty years, 
it is found that from 1804 to 1830 the ratio of mortality from these 
diseases is very variable ; the numbers are, however, too small 
during this period to be of much value, but for the last twenty years, 
when the number from each is considerably increased, it will be 
remarked that they show a decided tendency to increase together, 
and to diminish together, the ratio of mortality varying but little. 

Hospital gangrene differs from erysipelas probably more in its 
appearance and its results than in its nature. It is, perhaps, 
erysipelas intensified, and somewhat modified in the tendency to 
spread over the body. But as the two occur under the same circum- 
stances, and as they certainly have close alliances, what has been 
already said of one can hardly fail to be true of the other. 



254 

With regard to pathology, Dr. Clark feels compelled to with- 
hold his assent to the doctrine that this is a fever, and a fever only, 
under any circumstances. He has not yet seen a single puerperal 
woman die of an acute febrile disease of short duration, in whom 
there could not be found, on post-mortem examination, some lesion 
of an inflammatory character, while he admits that other writers 
have published observations of a different result. He thinks that in 
every case where a full examination is made, one of the four lesions 
(peritonitis, phlebitis, lymphangitis, endometritis,) will be found. 
Inflammation of the lymphatics is more common than inflammation 
of the veins. It is very often met with, to a limited extent, in the 
broad ligament, when the chief lesion is peritonitis. Another form 
of disease is that which Gooch, Simpson, and Tyler Smith, regard as 
independent of anatomical lesion. He says, the view which I wish 
to present of that class of cases is that they are probaby all, in 
reality, pyaemia, resulting from inflammation of the inner surface of 
the uterus. In order that what I have to say on this point may be 
better understood, we'will consider one or two points in the anatomy 
of the uterus after parturition. 

The uterine sinuses remain open, or rather openable, for at least 
ten days. Why do they not'bleed ? I do not know that any one has 
made an exposition of it ? If I see it correctly, these sinuses are 
guarded by a valvular opening like that of the ileo-coecal valve. 
There are two folds, the longest is the innermost one ; through this 
inner fold there is a muscular fibre well marked, and, also, a smaller 
muscular fibre running through the shorter lip ; these muscular 
fibres are continuous with the muscular fibre of the body of the 
uterus ; when the muscular fibre of the uterus is well contracted, the 
shorter lip is drawn down on the inner one so that no blood escapes. 
When the muscular tissue is relaxed, the mouths open in this way 
(illustrated by two pieces of paper, the one overlapping the other, 
like the two parts of the ileo-coecal valve, and the ends approxi- 
mated) ; thus it is that bleeding occurs when the uterus is relaxed, 
and hence the necessity of having the uterus contract to prevent 
haemorrhage. 

If the open body of one of these sinuses be lifted, a sort of sac will 
be found one-sixteenth of an inch or so in depth ; and, looking to- 
ward the wall of the organ, another little mouth, sometimes two or 
more ; whether that has a muscular fibre I am unable to say. 

Inflammation of the inner surface of the uterus is, also, inflamma- 
tion of the valvular mouths of the uterine sinuses, since they are 
really a part of this inner surface ; hence endometritis, as it seems 
to me well to denominate it, is of necessity a limited phlebitis, and 
inflammation of this inner surface of the uterus is of common occur- 
rence, in one or other of its forms. Cruveilhier has described it as 
attended by an exudation which is soft, vascular, and areolar, the 
meshes of which are filled with blood clots. I have seen the exact 
copy of what he represents in Plate VI., of Book 4 ; and can state 
that the singular appearances there illustrated, are due to fibrin, pus, 
and blood ; the first forming a velvety surface on the interior of the 
uterus, which holds in its fibres the, other two, and that there is no 



255 

proper vascularity in this exudation ; it is nothing more than one of 
the least frequent of the results of endometritis. The more common 
results of the inflammation, are exudations of a creamy consistency, 
varying in color from a pale pink, through a brick-dust to a brown- 
ish red, or saneous hue, with or without a firmer fibrinous layer, in 
contact with the uterine surface ; in rare instances the color is the 
dark green, represented by Cruveilhier. 

When this endometritis exists with the symptoms of puerperal 
fever, though peritonitis be absent, and though pus be not found in 
the lymphatics or veins of the uterus, yet we are not at liberty to in- 
fer that the disease is a fever and nothing else. Here is a source of 
purulent contamination. That pus is not found in the veins is not 
proof that it does not exist in the circulation ; formed within the 
mouths of these sinuses, it would be readily washed into the circula- 
ting blood, and produce the symptoms of pyaemia. Indeed, the proof 
of such contamination I have seen in the deposit of pus within the 
tissue of the liver. 

Dr. Reese remarked, that a law should be enacted to prevent per- 
sons from attending on puerperal women, after attending cases of 
erysipelas, hospital gangrene, or autopsies. He had never seen a 
case which justified the view of this disease being contagious. He 
had not found local lesions sufficient to account for its fatal results. 

Dr. Smith said that Prof. Clark did not discriminate between 
typhus in males and typhus in females ; if he had excluded the 
typhus in males, perhaps the results would have been more equal. 

Dr. Clark answers that, though he is unable to furnish statistical 
accounts at present, he is satisfied that typhus fever takes its full 
proportion of females, and in epidemics more females are lost, be- 
cause females are more about the sick. He believes to have seen 
the cases which Gooch, Simpson, and others describe as puerperal 
fever, without lesions, and to have never failed to find the evidences 
of endometritis. Puerperal fever is a purulent contamination of the 
blood, in a manner already explained, and the patient dies, not of 
endometritis, but of pyaemia. A febrile element cannot be excluded 
from this disease, but it is accompanied by, if not dependent upon a 
local lesion. Lately a form of puerperal fever was observed at 
Bellevue Hospital which was not noticed on former occasions, the 
nature of which has not been so thoroughly studied by the profession 
as that of other forms. Its prominent lesion is inflammation of the 
inner surface of the uterus, with evidences of general purulent con- 
tamination ; and the disease is unusually protracted. The patients 
have lived in several cases from ten to thirty days ; and the post- 
mortem examinations have demonstrated the existence of secondary 
purulent deposits, and pus on the inner surface of the uterus, and in 
its veins or lymphatics, This form of disease is more insidious in its 
approach ; is often devoid of the symptoms that mark the outset of 
the ordinary attacks of puerperal fever, and is more allied to typhoid 
fever. The minutes of ten cases, illustrating the foregoing remarks, 
are given by Dr. Clark. In most of these cases, all the symptoms 
on which reliance usually is placed in the diagnosis of puerperal 
fever were absent at the commencement. No chill, no headache, no 



256 

pain in abdomen, no rapid rise in the pulse ; in fine, no well marked 
period of invasion. The disease was marked by its gradual progress. 
In the first narrated case, the characteristic point was the recurrence 
of the chill, and the long perspiration that follows the chill, or of free 
perspiration without chills. The solitary glands of the intestines 
were swollen, filled with a milky fluid, and stood out on the surface 
of the mucous membrane, in certain parts, like pustules, as they often 
do in smallpox and cholera. Dr. Clark remarks, that he had been in- 
duced lately to attach importance to this lesion and its connections 
with pyaemia, having met with it frequently during the epidemic 
here described ; and in some cases of purulent infection unconnected 
with the puerperal state. Thus the analogies of this case, all ally it 
to common purulent phlebitis. Such it undoubtedly would have 
been considered, had it occurred in any other than the puerperal 
state, or even in this state, perhaps, if it had occurred alone. But 
its associates are no less important than the disease itself. It 
occurred at the end of a series of eleven cases, four of which had the 
peritoneal inflammatory lesions, and six appeared to suffer mainly from 
uterine phlebitis and pyaemia. Nine of the other ten cases occurred 
between the second and the twelfth of April. Whether this form of 
phlebitis should be considered a form of puerperal fever, may admit 
of discussion, but it certainly appears in an epidemic form. 

Dr. Barker feels compelled to differ from Dr. Clark's views, having 
been accustomed to regard the local lesions as being the relation of 
an effect, instead of a cause. There is a proportionate relation 
between the intensity of the symptoms and the amount of the local 
lesion. Puerperal fever is a distinct essential disease, and associated 
with it are .most generally lesions of the peritoneum, or of the veins 
of the uterus, etc., while we may have peritonitis, or phlebitis, or any 
other of the local inflammations, even in the puerperal women, and 
not have puerperal fever. Puerperal fever is a cymotic disease, 
having an essentiality altogether distinct from inflammation of any 
tissue, or structure of the body, even in a puerperal woman. The 
puerperal state, per 8e, cannot alter in any sense the laws which 
govern inflammation. It undoubtedly does increase, under certain 
circumstances, the susceptibility to inflammatory action ; but it 
may, and often does, produce a condition of the system directly 
antagonistic to inflammation, and it is precisely in this latter condi- 
tion that we find the most virulent, the most intractable forms of 
puerperal fever. Puerperal fever has no anatomical character. The 
structural lesions are inconstant in their seat and their amount. 
These lesions are. often not sufficient to influence the progress of the 
disease, or to explain the cause of death. The most malignant form 
of the disease offers the fewest and the least striking structural 
lesions. The longer the disease continues, the more prominent and 
the more manifest are the organic lesions. Does not this prove that 
the lesions are consecutive or secondary ? That there is a primitive 
source or original cause of vital depression, which sometimes 
destroys life so rapidly that there is no time for the development of 
these secondary morbid alterations ? The symptoms are not then 
the result of these lesions, but the result of some specific agent, some 



257 

morbid poison, which subsequently develops the autopsic lesions. 
We may have inflammation, even to an intense degree, of any of the 
organs in a puerperal woman, in which the principal lesions of puer- 
peral fever are found, and yet the disease will lack some of the 
essential characteristics of puerperal fever. We may have f. i. 
uterine phlebitis, and not have puerperal fever. There is a great 
contrast between the two as regards the mode of attack, symptoms, 
and treatment. The difference being that the one disease follows the 
laws of ordinary inflammation, and that in the other the toxaemic 
origin of the disease gives it quite a different character. These 
differences were strikingly illustrated in the recent epidemic at 
Bellevue Hospital. In the latter part of January, succeeding a period 
of almost unparalleled cold, came that long spell of warm, damp, 
close, foggy weather. This change had scarcely set in, when one 
after another, as the women were delivered — these wards having 
been previously perfectly healthy — they began to develop, one pelvic 
cellulitis, another peritonitis, another metritis, all of the asthenic 
type, and with an early tendency to gangrene or suppuration ; while 
scarce one escaped without a threatening, at least, of those terrible 
torments of nursing women, sore nipples or mammary abscess. 
Indeed, so well established did this state of things become, that a 
pulse of 120 and a flushed cheek were looked for as matters of course 
on the morning after confinement, and the pleasant soft pulse and 
cool skin of the physiological recovery were luxuries which the 
attendant physicians dwelt long and lovingly upon, when, at long 
intervals, they presented themselves. These cases, notwithstanding 
that they bore the outward semblance of inflammations, were yet, in 
their mode of progression, constitutional effects, and indications for 
treatment, so different from the ordinary phlegmasia, as to lead Dr. 
Barker to announce his belief in the specific character of these dis- 
eases ; that the quasi-inflammatory processes taken on by these 
organs were, in reality, the results of the action of a poison infused 
into them through the blood, and stirring up its peculiar excitement 
wherever it found the proper amount of combined irritation and 
exhaustion to insure it a nidus ; just as the typhoid poison awakens 
its deceptive pseudo-inflammations in the brain, the lungs, the intes- 
tines. " Treat these cases," said he, " as idiopathic inflammations, and 
you must inevitably kill your patients." Most of these cases were 
treated successfully, by early local derivation or depletion, followed, 
or even accompanied, by profuse general stimulation. Three, how- 
ever, terminated fatally ; two by suppuration into the pelvic cavity, 
and purulent absorption, in one of which a large number of abscesses, 
from the size of a walnut down, were found in the lungs ; and one 
by gangrene of the cervix, extending to the mucous membrane of the 
body, and involving to a slight extent the posterior walls. 

The next point to which Dr. B. called attention, was that the le- 
sions themselves differ materially from those having an inflamma- 
tory origin. Prof. Murphy has so clearly pointed out these distinc- 
tions that no apology is necessary for quoting them : 

"In peritonitis, all the arterial capillaries are highly injected: 
hence the intestines are streaked with bright red lines of capillaries 
17 



258 

that encircle them. In puerperal fever, the venous capillaries predom- 
inate ; hence the livid hue of the intestines, and the dusky red color 
of the patches and streaks on their surface. In peritonitis, the lymph 
which is poured out is adhesive, uniting the different parts like glue: 
if removed from the surface of the intestine on which it is deposited, 
the strings of this lymph are broken across, and the surface is rough; 
the quantity of serum poured out is not great, and, being lodged in 
the cavity of the pelvis, may at first escape observation. In puer- 
peral fever, that which we call lymph is not adhesive: it is much 
more abundant than adhesive lymph, covering the fundus of the 
uterus, the intestines, the liver, the diaphragm ; it is found also in 
the pleura ; its color varies from a dusky brown to a pale yellow ; 
it may be peeled off the liver, the intestines, or the uterus, quite 
easily; the surface from which it is taken is smooth, and that of the 
intestines is a dark red color. The quantity of serum is equally 
profuse ; and this substance being dissolved in it, gives it a lactes- 
cent appearance like pus ; hence, it is called sero-purulent fluid. 
Thus, when the abdomen is opened, a large quantity of this fluid 
always escapes. It will be objected that this sero-purulent fluid is 
also met with in peritonitis. This is perfectly true ; but it is neces- 
sary to note the stage of the inflammation in which it is observed. 
I have never met with it unless in the second stage of the attack. 
When a patient died in the first stage, there was none of it. I con- 
clude, therefore, that in the former instance (the second stage) such 
effusions only occurred when the constitution was sinking under the 
attack ; but in the latter, when death took place from a different 
cause, the effusions noticed were the true products of inflammation. 
In puerperal fever, the greater the intensity of the seizure the less 
the chance of meeting anything like lymph. In the most intense 
forms no effusion at all may take place. In a degree less intense, a 
large quantity of serum, colored brown by blood, is found in the 
peritoneum and throughout the tissues : the lymph poured out is of 
the same color, having no adhesion to the surface on which it lies, 
as if the fibrin of disorganized blood had been deposited there. In 
the next degree, the same kind of lymph or fibrin is found, of a 
yellow color, with a quantity of sero-purulent fluid. And lastly, in 
those cases in which the constitution for a time struggles success- 
fully against the fever, some adhesive lymph will be met with, mixed 
up with a larger quantity of what I have just described." 

The next argument which he adduces in proof of the doctrine that 
puerperal fever is a zymotic disease, and not a local phlegmasia, is 
that simple inflammatory diseases are not communicable from one 
patient to another, through the medium of a third party. It may be 
objected that this argument assumes that puerperal fever is thus 
communicable, which is not proven, and is one of the points now 
under discussion. He says, " With all due deference to those present 
who may differ from me, if any such there be, I must be allowed to 
say, that I think no one fact in medicine is better established than 
this. The question of contagion is not one of abstract reasoning, but 
one of facts ; and, as to the facts, a few amounting to positive de- 
monstration, must be conclusive. Negative testimony is utterly 



259 

worthless in settling such a question. I should almost feel that I 
insulted the intelligence of those present by entering into an argu- 
ment on this point at the present day. Prof. Oliver Wendell Holmes, 
in his essay on the Contagiousness of Puerperal Fever, has brought 
an array of facts which must, I think, be convincing to every unpre- 
judiced mind. For myself, I would say with Dr. Blundell that, ' I 
had rather those I esteemed the most should be delivered unaided in 
a stable, by the manger-side, than that they should receive the best 
help, in the fairest apartment, but exposed to the vapors of this piti- 
less disease.' I would heartily concur with the emphatic declaration 
of Dr. Holmes that, 'if, on this point, there is any voluntary blind- 
ness, any interested oversight, any culpable negligence, even in such 
a matter, and the facts 6hall reach the public ear, the pestilence car- 
rier of the lying-in chamber must look to God for pardon, for man 
will never forgive him.' Now, then, if this disease is thus 
communicable, is there any other local phlegmasia which is thus 
communicable ? It may be objected that dysentery is sometimes 
contagious ; I think I have myself been through an epidemic of 
dysentery which was evidently contagious ; but I should answer, 
first, that it remains to be proved that this form of dysentery is 
simply a local phlegmasia ; and, second, that there is no evidence 
that a healthy person can communicate this disease from one person 
to another. 

" My next argument is, that the prophylaxis of puerperal fever is 
not the prophylaxis of local inflammation. In the large hospital of 
Vienna, from 1840 to 1846, one in every ten mothers delivered 
perished, chiefly from puerperal fever. In May, 1841, Dr. Semelweiss 
prevented students from touching parts at the autopsies, and direct- 
ed all of them to wash their hands in a solution of chlorine before 
and after every vaginal examination ; and the mortality from this 
time so far diminished that, in 1848, not above one in seventy-four 
mothers died. Does not this fact prove the toxaemic origin of the 
disease in these cases ; and that the local lesions are secondarj', re- 
active, and have less pathological value than the change which pre- 
cedes it ? It may be objected, that the views which have been ad- 
vanced as to the pathology of puerperal fever entirely ignore the 
existence of an epidemic influence ; and that, the epidemic influence 
may give a specific character to the local phlegmasia. From Syden- 
ham we have learned the phrase ' type of the season,' and another 
phrase has come into use, meaning nearly the same thing, viz., 
' epidemic constitution.' Now, what is meant by these terms ? 
Clearly they must refer to certain atmospheric or telluric influences, 
which modify the susceptibility of the system to disease, or which 
increase the virulence of the poison which develops disease. That 
this influence really exists, acting in both ways, I think there can be 
no doubt. It sometimes produces its influence wholly on the system, 
diminishing the vital resistance to disease, and rendering inflamma- 
tory action asthenic in its type ; or the opposite result may be pro- 
duced. So, also, it may increase the virulence of the poison which 
gives rise to the zymotic diseases. Puerperal fever is most notably 
susceptible to an epidemic influence. 



260 

" I have thus given my reasons for believing that puerperal fever is 
an essentiality, that it is a zymotic disease, resulting from the ab- 
sorption of a specific poison, and that its anatomical lesions are 
secondary." 

There is no specific therapeutics for puerperal fever. The sooner 
this idea is dismissed from the mind, the more probable is it that the 
treatment adopted will have a rational and philosophical basis. The 
method, of treatment must vary according to the condition of the 
system ; according to the virulence of the epidemic or special 
poison ; and according to the intensity and severity of its secondary 
lesions. The indications are : To eliminate from the system, as much 
as is possible, the morbid poison. This is accomplished by means of 
depletion and the other evacuants. Unfortunately this indication, 
owing to the peculiar character of this disease, can rarely be fulfilled, 
except to a limited degree. At the present day, the advocates of 
venesection are few in number. It proved to be the most efficient 
remedy in the epidemics met with by Gordon, Hey, Armstrong, and 
in one seen by Gooch. Venesection should never be resorted to 
simply because the case is one of puerperal fever, but because the 
symptoms indicate that depletion is necessary. The same principles 
should govern us in resorting to purgatives, emetics, diuretics, etc. 
The second indication is : To control the vital disturbances resulting 
from reaction These are principally vascular excitement and nervous 
irritation. We have in the materia medica an agent, lately brought 
prominently before the profession, which acts specifically as an 
arterial sedative, without depressing the vital powers. This is 
veratrum viride. Dr. Tully, of New Haven, first brought its medicin= 
al properties to public knowledge. By it the pulse can be brought 
under voluntary control. Dr. Barker has used it for several years in 
puerperal fever, and he asserts that in no disease he saw its value 
more strikingly exhibited. It is an agent which requires care in its 
use, and in those cases where its full efforts are required, the patient 
must be kept under careful medical watching and be seen at short 
intervals. Unfortunate results were never remarked from its use, 
but very severe temporary depression. 

"A case occurred at the hospital at the time of an epidemic, pre- 
senting a combination of symptoms, which all familiar with the dis- 
ease would pronounce truly alarming. By the verat. virid., the pulse 
was brought down from one hundred and forty to sixty per minute ; 
and it was never permitted to rise above eighty. The quantity 
administered varied according to the condition of the patient, two, 
three, or four drops being found sufficient to control the vascular ex- 
citement. In many other puerperal cases I have seen equally striking 
results. I will briefly mention one which I saw in consultation with 
Dr. Sayre, the tenth day after confinement. She was a primapara, 
and her convalescence seemed perfectly normal until the sixth day, 
when she began to exhibit some appearance of mental disturbance. 
She was especially anxious in regard to her religious condition. 
Gradually a high state of nervous excitement was developed with 
insomnia, and when seen by myself she had been decidedly maniacal 
for more than twenty-four hours. Her respiration was short and 



261 

hurried, her pulse very rapid, her countenance anxious and frighten- 
ed ; she was incessantly talking", and starting with apprehension 
from the slightest movement in the room. No physical exploration 
could be obtained, but there were no local symptoms indicating 
pelvic trouble. She sat up in bed and moved from one part to 
another with great rapidity. The verat.virid. was now given, and 
by its influence the pulse was brought down below seventy per 
minute, the respiration became slower, the mind tranquil, and she 
was enabled to sleep. I am informed by Dr. Sayre that, in the course 
of a few days, there was developed in the pelvic cavity an extensive 
abscess, which pointed externally, near the sacrum. Her convales- 
cence was somewhat prolonged, but she eventually recovered." 

There is a vast difference in the power of the herb grown at the 
South, compared with that grown at the North. Seven*drops is a 
large dose of the tincture prepared at the South. 

The opium treatment is most successful in "puerperal fever with 
peritoneal lesion." It is astonishing to see to what extent patients 
will tolerate opium where the peritoneal lesion predominates ; but it 
is only in this form of fever that this great tolerance exists. There 
is one point to which attention must be called, and that is a test 
whether the action of this drug is proving beneficial or not. If opium 
be pushed to incipient narcotism, a gradual decrease in the frequency 
of the respiration results. Now, the opium treatment is acting bene- 
ficially, when, in connection with the reduction of the frequency of the 
respiration, there is a corresponding decrease in the frequency of the 
pulse ; but if with incipient narcotism the respiration grows slower 
and slower, without a corresponding decrease in the pulse, the opium 
treatment is to be abandoned at once. Dr. B. said : " In one case 
that occurred at Bellevue Hospital some two years since, the opium 
had been pushed to such an extent that galvanism had been resorted 
to to make her breathe. When I saw her the respirations were 10 
and 11 per minute, while the pulse was above 140 per minute. 
Seeing this slow respiration with the frequent pulse, I suggested 
that no more opium should be administered, as I thought its con- 
tinued use would overwhelm the vital powers. The veratrum viride 
was then given, and in a few hours the pulse came down below 80. 
This patient eventually recovered. I will state, then, as my convic- 
tion, that in that class of cases where the peritoneal lesion predomi- 
nates, the opium treatment has proved successful to an extent which 
no other has." In many cases, to control the vital disturbances 
resulting from reaction, it will be necessary to use a variety of 
agents to accomplish this end. Venesection, veratrum viride, opium 
in full doses, camphor, etc. Two cases in illustration of this are re- 
corded by Dr. Barker. 

Third. — To combat the local secondary lesions which may be develop- 
ed by local depletion, counter-irritation, fomentations, chlorinated in- 
jections, etc. Another indication is, to sustain the vital powers of the 
system ; in other words, keep the patient alive. There is a certain 
class of cases where the system seems to be overwhelmed, and yet 
life will be preserved by the heroic use of stimulant and good nutri- 
tion. Many patients no doubt are permitted to die from the neglect 



262 

of these resources. After a patient has lived for forty-eight hours, 
there is constant encouragement for effort, and that the danger is, in 
a certain sense, diminished in proportion to the duration of the dis- 
ease. 

Dr. Clark said he had expressed his concurrence in the views of 
those who believe the disease to be contagious ; in his belief the dis- 
ease is composed of two elements — a fever and an inflammation. In 
this respect it resembles the epidemic dysentery, the epidemic erysi- 
pelas, or small pox. In the epidemic erysipelas which prevailed in New 
England and in the Western States, from seventeen to ten years ago, 
these two elements were as clearly distinct, in the time of their de- 
velopment, as they are in small pox — a febrile movement preceded 
the grave inflammatory lesion. This same erysipelatous disease 
assumed, in lying-in women and those in the puerperal state, the 
form of puerperal fever. He believed that the puerperal disease is 
never fatal but by the aid of its inflammatory element. He believed 
that the cases reported without lesion of any kind were no exception 
to the general rule, and that they were really marked by inflamma- 
tion, but that the inflammation was one that had escaped detection ; 
that it was an endometritis, and that the inflammation affecting the 
inner surface of the uterus involved the open or valvular mouths of 
the uterine veins, and might produce purulent contamination of the 
system, while no pus was found in the veins themselves after death. 
The evidence of this was in the inflammatory exudation on the inside 
surface of the uterus ; the redness of the' uterine structure, penetrat- 
ing a minute distance from within outward ; the symptoms of 
pyaemia and the discovery of pus in distant organs. In objection to 
Dr. Barker's remark, that the most malignant forms of puerperal 
fever were void of any local lesions, Dr. Clark reports a number of 
cases of very short duration (from 33 to 48 hours) having occurred 
in Bellevue Hospital in 1840. In all these short cases there was evi- 
dence of inflammatory lesion of the peritoneum ; in all but one there 
was a morbid exudation on the inner surface of the uterus, and in 
this one the inner surface of the organ had not been particularly in- 
spected by those who made the dissection. 

From the researches of Dr. Sedillot, it appears that injection of 
serum of ill-conditioned pus into the veins of dogs, was followed by 
rapid death* without any formation of metastatic abscesses. The 
import of these experiments, and their relation to the disease in 
question, is evident, especially when, it is remembered that the 
uterine cavity is open to the ready access of air ; that when inflam- 
mation has been recognized on its inner surface, it has often been of 
a character most likely to furnish a septic agent ; and that the veins 
of the uterus are, after parturition, so arranged as to receive such 
septic agent, healthy or degenerated pus, in an augmenting, and, 
consequently, accumulative stream. Dr. Clark, after giving the 
history of opium treatment in ordinary peritonitis, remarks, that the 
confidence in the opium treatment of puerperal fever, with peritoneal 
complication, is in no degree sliaken by accumulating experience, 
but is rather increased ; while its usefulness in that form of the dis- 
ease which is attended by purulent infection, has not been demon- 



263 

strated, at least as an exclusive method. With regard to the mode 
of administering opium, Dr. Clark refers to a letter written in 1829, 
by Dr. F. G. King, and directed to Dr. V. Mott, in which, the dose 
mentioned is from 70 to 100 drops of laudanum, given repeatedly at 
short intervals, till the full influence of the drug is developed. 

With regard to treatment, Dr. Barker said : " The value of vera- 
trum viride in reducing vascular excitement has in this disease been 
confirmed by many observers in this city and my own additional ex- 
perience. It will most surely reduce the quickened. pulse of inflam- 
mation and irritation. Its use is not incompatible with that of 
stimulants. Experience has abundantly demonstrated the truth of 
this apparent paradox. One patient who recovered took, every hour 
for two days, one ounce of brandy and fr,om three to ten drops of the 
tine, veratrum viride, the quantity of the latter being determined by 
the frequency of the pulse, which was never allowed to rise above 
80 per minute, although it sometimes fell down to 40. In another 
case the veratrum viride did not seem to produce any effect on the 
pulse, which remained steadily above 130, until, the condition of the 
patient was such that I decided to give brandy. After the first 
ounce was given, it fell to 108 ; after the second, to 86. Continuing 
the brandy, the veratrum viride was suspended for a few hours, and 
the pulse again rose to 130. After this it was curious to note the 
fact, that if either agent was suspended the pulse would rapidly in- 
crease in frequency, while under the combined influence of the two it 
was kept below 80 per minute. I have little to add to what has 
already been said on the use of opium in puerperal fever. In all 
cases it should be given to the extent of entirely subduing the pain. 
When the peritoneal lesion predominates, it is the principal agent on 
which we must rely, and the quantity in which it is to be adminis- 
tered is only to be determined by the effect which it produces. 

" To combat the local secondary lesions, a great variety of means 
have been proposed, which will often tax the resources of the medical 
attendant to the utmost. I have already spoken of the value of 
opium in the peritoneal lesion. The tympanitis is often the most 
striking and distressing symptom, and I regret to say that I know 
of no treatment by which we can always be sure of relieving it. I 
rely, however, mostly on the use of turpentine, internally and ender- 
matically. In some cases I have seen good results from the use of the 
acetate of lead, and in others I have seen all means fail. In those 
cases where the secondary lesions arc developed in the uterus, its 
veins, or its lymphatics, I have seen no advantage from leeching or 
blistering. The exposure of the abdomen to the air more than coun- 
terbalances the problematical advantages resulting from the former, 
while the latter only adds to the nervous irritation already existing. 
In these cases, the only local treatment I make use of is chlorinated 
vaginal injections, repeated several times a day, and hot linseed 
meal poultices kept constantly applied over the hypogastrium. « 

" Finally, the vital powers of the system must be sustained. I 
believe more patients die from the neglect of this point than from 
any other error of treatment in this disease. The patient is often 
sacrificed by a contest between the doctor and the disease, both con- 



264 

tributing to exhaust the vital powers. In very many cases remedies 
are utterly powerless in combating the disease, and the province of 
the physician is to keep the patient alive until the disease is ex- 
hausted. This can only be done by proper nutrition, and the pre- 
vention of waste and the restoration of nerve power by the use of 
alcoholic stimulants. I. will' not enlarge upon this point ; but I still 
believe that when a patient with puerperal fever has lived for forty- 
eight hours, there is constant encouragement for effort, and that the 
danger is in a certain sense diminished in proportion to the duration 
of the disease. I will only allude to two points of practice which 
seem to me of some importance. The first I have already mentioned, 
the value of a mercurial laxative when the patient has been support- 
ed for some days by the liberal use of beef-tea and alcoholic stimu- 
lants until the stomach loses the power of taking care of what is put 
into it, apparently from obstruction of the portal circulation and 
congestion of the capillary circulation of the mucous membrane of 
the alimentary canal. 

" There is another class of cases where the stomach seems to give 
out all at once from another cause which I will not undertake to ex- 
plain. Everything is rejected in a few minutes after it is swallowed, 
with a painful feeling of burning and excoriation. Now, if this con- 
dition is not changed the patient will soon die, as she can no longer 
be sustained. I have in several instances been able to persuade the 
stomach to resume its functions by adding to each table-spoonful of 
beef-tea one drop of nitro-muriatic acid, the proportion of the mixture 
being one part of the nitric and two of the hydrochloric acid." 

Dr. Auber's work contains a critical review of the discussion in 
the Paris Academy of Medicine, and is intended to prove the exist- 
ence : 1st, of a peculiar puerperal state with consecutive, specific, 
puerperal phenomena ; 2d, of a real (legitime) puerperal fever, 
originating from the absorption of the lochia and milk ; 3d, of an 
epidemic puerperal fever ; and 4th, of a puerperal typhus, being an 
occasional result of putrid miasmas, developed in rooms overcrowded 
with women in childbed. 

Dr. Tarnier's book on puerperal fever is one of the most important 
articles on this subject, written in France. He first treats of the 
pathological anatomy, based upon a large ■ number of post-mortem 
examinations. He found the blood changed in all cases examined ; 
the alterations were those indicated by Dr. Vogel. In speaking of 
uterine phlebitis, he says that according to his experience the so 
called metastatic abscesses were only exceptional coincidences with 
phlebitis. Virchow is of a different opinion, and very likely Dr. T. 
has taken cases of lymphangitis for phlebitis. By a microscopical 
examination the puriform liquid in the fallopian tubes was found to 
be of a two-fold nature, one consisting of regular pus globules, one 
of a transparent liquid with an abundant quantity of epithelial cells. 
The liver is very often found in a state of fatty degeneration, which 
is due not to puerperal fever, but to the physiological condition of 
the puerperal state. The importance of symptoms with regard to 
the hard string, representing the inflamed fallopian tubes, and 
which Behier considers as an unfailing sign of approaching puer- 



265 

peral fever, is admitted, still he does not consider this lesion as a 
prodrome, and much less as the first period of the fever. The first 
chill was never remarked as far as eight days after delivery ; as a 
general rule it sets in immediately after confinement. In genuine 
puerperal fever there is only one or two initial chills, while its 
frequent repetition is rather an indication of purulent or putrid 
infection. 

COURSE, DURATION. 

Out of a number of 6t cases — 

Died in 38 hours « 1 

" 39 " • 1 

" 2 days 4 

« 3 « 9 

" 4 " j 19 

" 5 « 15 

" 6 " 10 

" 7 " 5 

* 8 « : 1 

* 9 " .• 2 

" 10 " or more 

In the epidemic of 1856, which lasted from the beginning of April 
to May 10th, when the Maternite* was closed, 64 women died of puer- 
peral fever, during which time 347 women were delivered. The 
hospital was reopened on June 21st, and during the month of Sep- 
tember another epidemic began to rage, so that 21 deaths were re- 
corded out of 266 confinements. At the end of October the disease 
had entirely disappeared. 

Etiology. — With regard to the influence of the season upon the 
origin of the fever, Dr. Lasserre has reported the distribution of the 
disease during 12 years. He found 

3 epidemics in January. 

5 " " February. 

3 " " March. 

1 " " April. 

1 " " June. 

3 * M July. 

2 « " August. 

1 " " October. 

1 " " November. 

3 * " December. 

In the same space of time, the six cold months furnished 868 
deaths of 18,108 confinements; the six warm months 465 deaths of 
15,956 confinements. 

After Dr. Lasserre's and Dr. Tarnier's researches, it appears that 
the mortality is less among women who have been living for some 
time inside the hospital walls, while those who entered shortly be- 
fore delivery are much more severely taken with the disease, and so 
are the primiparous women. The generally adopted view that a 
dead foetus in the uterus had an influence upon the development of 
the disease, has been refuted by Dr. Dubois. Out of 89 still-born 
children in 1856, 6 only were born of women who afterwards died of 
puerperal fever. 



266 

In discussing the question of contagion, Dr. Tarnier does not hesi- 
tate to pronounce in the affirmative. During 1856 there were 

At the Maternity— 2.237 confinements and 132 deaths. 
At the Clinique — 630 confinements and 51 deaths. 

During the closure of these hospitals, a portion of the pregnant 
women were received at the hopital Cochin, and soon the same mor- 
tality was established, viz. : 16 deaths out of 206 confinements, 
while in the city only 14 deaths were noted down out of 3,222 
women. The author himself had occasion to treat one of the nurses in 
the Maternite during her monthly courses, for a disease which resembled 
exactly puerperal fever. She died in three days, and the peritoneum 
was found to contain a large quantity of purulent scrum ; the womb 
appeared perfectly healthy. Another nurse was taken, while she had 
her courses, with similar and very alarming symptoms, but she 
finally recovered. A similar fact has been reported by Dr. Depaul 
(Union Mddicale, 1855, No. 26), and Drs. Pubois, Danyau, Voillemier 
have seen the same. Moreover, at the time when the disease was at 
its hight an unusually large number of new-born children died, viz.: 
18 out of 302 ; this was from April 1st to May 10th, a per centage 
four times larger than that of the entire year ; and most of the 
children who died, were born from mothers not taken with the fever. 
The question whether a physician is liable to propagate the fever per- 
sonally, from one person to another, Dr. Tarnier is inclined to an- 
swer in the affirmative. To prove this he alludes to the many obser- 
vations brought forward in the discussion of the Paris Academy of 
Medicine, by Drs. Danyau and Dubois ; he Says : " If puerperal fever 
was only an epidemic disease, it would spread with an equal force 
outside as well as inside the hospitals, but it has been demonstrated 
that this is not the case. The puerperal poison does not only infect 
women in the puerperal state, but also non-pregnant, quite young 
women, and new-born children." 

As a prophylactic remedy, Dr. Tarnier proposes to have the hos- 
pitals constructed so that only one woman is received in a room 
during confinement, to remain there for fourteen days ; this room to 
be well aired and cleaned afterwards, and left unoccupied for 14 more 
days. Moreover, the pregnant women ought to be received in the 
hospital at least 14 days before delivery, in order to get acclimatized 
to the hospital air, experience having shown, that women received 
shortly before their confinement are more prone to catch the fever 
than those who have been there for a greater length of time. With 
regard to treatment Dr. Tarnier is in favor of administering an 
emetico-cathartic, in those cases where bilious symptoms are present. 
The use of mercury he thinks, is of no avail, as he himself has never 
succeeded in producing salivation. In epidemics of a very serious 
character, the administration of quinine has had not the least in- 
fluence. Dr. Delpech has applied the bichromate of potash, and two 
very bad cases were cured. Still the remedy has been tried too 
little to allow of a final decision. 

As to the nature of the disease, two principal objections can be 
raised against those who advocate its local genesis. First, it is im- 



267 

possible during a well-marked epidemic to make a distinction be- 
tween puerperal peritonitis, pleuritis, phlebitis, or lymphangitis, while 
on the other hand a great number of observations are known where 
the most scrutinous examination was at a loss to detect the slightest 
trace of local disease. The epidemic and contagious character of 
puerperal fever, are a sufficient proof that it is a general and not a 
local disease. Dr. Tarnier remarks that, metro-peritonitis, uterine ' 
phlebitis and angioleucitis, purulent and putrid infection, are acci- 
dents to which puerperal women are at times subjected ; but in this 
case they represent peculiar diseases for themselves, which can be 
distinguished from puerperal fever. The puerperal fever, according to 
Dr. Tarnier, is due to a poison, a morbid fermentation, which may 
take its origin spontaneously in the organism, under the influence of 
certain unknown conditions, which at times forms or enters into the 
system by an epidemic influence, which at times is propagated 
from one woman to another, by the different modes of contagion. 
The diseases which puerperal fever resembles in many points, are 
the epizootic pneumonia and army-typhus. The thesis is concluded 
by a number of very interesting observations. 

Dr. Murphy considers puerperal fever as the consequence of a 
poison, affecting the blood, which has a disposition to exudations 
from the serous membranes. The fibrin of the blood already present 
in a larger proportion, is altered in its chemical constitution ; hence, 
the profuse exudations of a diseased fibrin. It is not adhesive, but 
decays in a pultaceous mass ; the veins are filled with dissolved, 
purulent fibrin. The poison proper to puerperal fever seems to have 
an opposite effect to that of typhus fever ; the former increases, the 
latter diminishes the quantity of fibrin. The character of the dis- 
ease is modified by the quantity of poison received in the organism. 
With regard to treatment, it must be remarked, that the use of 
ipecacuanha saved many patients in some epidemics. Dr. M. pro- 
poses to try chloroform as a specific remedy against the disease, 
with a view to destroy the poisoning element in the blood. 
^ Dr. Pidoux remarks that puerperal fever comprises a series of affec- 
tions of a varying form and localization, the climax of which was 
represented in the puerperal typhus. This typhus is almost ex- 
clusively observed in overcrowded wards, and the only reliable 
treatment for it is a thorough alteration in the construction of the 
lying-in hospitals. 

Dr. Simpson advocates the possibility of transmission of puerperal 
fever from one person to another by the attending physician, and 
even believes that a typhus patient can produce puerperal fever in a 
puerperal woman by his exhalations. 

Dr. Beiiier, a pupil of Trousseau, considers phlebitis and purulent 
absorption as the principal cause of puerperal fever. It is no disease 
peculiar to women in childbed, but has been observed in persons 
being neither pregnant nor in the puerperal state. 

Dr. Surmay believes that the extensive production of pus in puer- 
peral fever, was owing to a general suppurative or inflammatory 
disposition. The pathological condition produced by this profuse 
suppuration does not produce a specific disease, but only a peculiar 



268 

form of disease, which is the representation of the general inflam- 
matory state. 

Dr. Brochin defends M. Bouillaud's theories, who does not believe 
in a specific puerperal fever. The fever is of an inflammatory or of 
a typhoid nature, which depends from its sporadic or epidemic char- 
acter. With regard to treatment, Dr. B. insists upon checking the 
progress of the disease by early attendance, and proposes to have 
the actual state of our lying-in hospitals thoroughly altered. 

Dr. Cros advocates the use of calomel and mercurial ointment for 
the treatment of puerperal fever ; 120 or 140 grmm. to be applied 
for the space of three days. 

Dr. Legroux is essentialist, inasmuch as he recognizes an unknown 
general cause, which invades the organism, and thus produces the 
disease. This cause shows a different intensity, and a changing char- 
acter in the different epidemics. The presence of the puerperal state 
is indispensable for this cause, to develop its effect upon the system. 
Besides this epidemic influence, colds or other injuries are apt to pro- 
duce severe puerperal diseases, in which case the purulent or putrid 
infection takes the place of the epidemic influence. Both sporadic 
and epidemic puerperal fever present a series of symptoms different 
in one and in the other instance, while they assume the same charac- 
ter, and exhibit the same anatomical lesion at a more advanced 
state. The disease becomes contagious under certain conditions, but 
this is not a characteristic symptom of the fever. The treatment has 
to be adapted to, and modified after the peculiarities proper to every 
single case. As soon as a violent chill appears, first of all an emetic 
has to be administered, in order to produce sweat, contraction of the 
womb, and a retardation of the pulse. If, after this the fever con- 
tinues, quinine ought to be given in large doses. 

The epidemic alluded to by Prof. Virchow, extended from the fall 
of 1856 up to February, 1858, making eighteen months altogether. 
The fever was at its hight in both winters, confirming a fact men- 
tioned already in 1847 by Dr. V., that the disease is more prevalent 
in winter than at any other season, thus contrasting with the so- 
called traumatic fever, which is more prevalent in summer time. In 
almost every case, the postmortem discovered some localized affec- 
tion. One of the most surprising features, was the frequent presence 
of recent endocarditis, with undoubted symptoms of puerperal fever 
during life. The affection, in most cases, had involved the mitral 
valve. In some of these it could be stated, that particles from the 
diseased valve had been removed, swept away with the current of 
blood, and deposited in distant localities, thus obstructing capil- 
laries, and causing local inflammations, phenomena which hitherto 
have always been called metastatic and pysemic deposits. The par- 
ticles from the mitral were recognized in these embolic deposits by 
treatment with a solution of caustic potassa, by which fresh fibrinous 
concretions are partially dissolved, while the fragments from the 
heart underwent no change. In these cases, the uterus was found 
perfectly healthy, and the symptoms of puerperal fever started ex- 
clusively from this affection of the heart. The author met with four 
cases of this kind, in one of which the sudden death was caused by a 



269 

malaria of the entire heart. He therefore considers this endocarditis 
of a puerperal character, and thinks the condition of the heart ought 
to be more generally considered in cases of so-called metastatic affec- 
tions, especially if the state of the abdomen does not sufficiently ex- 
plain either the violence of the disease, or the frequency of the pulse. 

At the time when the epidemic was at its hight, most of the cases 
were of a peritoneal character, among which the greatest number 
was free from metastases. The nature of this peritoneal inflamma- 
tion showed two distinct forms ; one was a mere superficial periton- 
itis with partly plastic, partly purulent exudation ; the other, more 
dangerous, was of a diphtheritic character, the effusion of which spread 
to the deeper layers of cellular tissue, which afterwards degenerated, 
thus presenting a mixture of detritus and pus. This is the same 
diphtheritic process, which, in so many instances, seizes the inner 
portion of the womb. 

In one case the uterus itself was the seat of inflammation, which 
resulted in gangrene. Of more common occurrence was ovaritis, 
representing also two different forms, viz., a superficial inflamma- 
tion, resulting in abscess of one or more follicles, which, by ruptur- 
ing, gave rise to violent peritonitis ; or a diffuse inflammation of the 
parenchyma, leading to considerable enlargement and malacia of the 
ovary. 

At other times, phlebitis prevailed, generally connected with 
metastases, which find a natural explanation, if considered as embol- 
ias. Inflammation of the lymphatics was scarcely ever followed by 
metastases, which finds its natural explanation in the fact that the 
greater number of lymphatics take their course through the lymphatic 
glands, in which larger particles may be retained, and may produce 
lymphangitis, but not vascular thrombosis. These latter affections 
are generally connected with rupture of the perineum or vagina, or 
lacerations of the cervix uteri, and are often complicated with gan- 
grenous destructions of the cellular tissue in the pelvis and fossa 
iliaca. 

Dr. Lehmann's article is a report on puerperal fever representing 
the views of the Obstetric Society of Amsterdam. It appears that 
the physicians of Holland consider puerperal fever as a primitive 
disease of the blood, produced by the influence of a miasma, which 
secondarily affects different local diseases. Both fever and local 
lesions have one common source, viz., the primary alteration of the 
blood. In some epidemics the fever prevails, in others the inflam- 
mations. The alteration of the blood may be primary, i. e., originate 
in the blood itself, or secondary, by resorption of septic particles. 
With regard to prophylactic treatment, the secale takes the 
first place in those very numerous cases where the uterus had 
not been sufficiently contracted after every labor of considerable du- 
ration, and whenever the afterpains are unusually strong, morphium 
ought to be administered. In no disease the "principiis obsta" must 
be more strictly observed. The general treatment consists of febri- 
fuges (quinine, digitalis, aconite), antizymotic (mercury, nitrate of 
silver, arsenic), and antipysemic remedies (chlor., kreosot, mineral 
acids); the local treatment embraces poultices, bleeding, opium 
enemata, and vaginal injections. 



270 

Dr. O'Reilly's article is intended to reconcile the diverging ideas 
on puerperal fever, by identifying it with e^sipelas. 

From an analysis of Prof. Pellizari's lectures, it appears that he 
considers puerperal fever to be essentially nothing but a purulent 
infection. Professors Vannoni and Bnffanini, seem to be of the same 
opinion. The different forms of the disease are explained by the dif- 
ferent locality from which the infection takes place, and the differ- 
ent quality of pus introduced into the system. Moreover, the differ- 
ent constitutions of the women taken, impress a different character 
upon the course of the disease. 

As predisposing causes, thirteen conditions are considered, which 
may favor purulent absorption. Among these, absorptions of pus 
by the fallopian tubes, and its promotion through this channel from 
the uterus to the peritoneal cavity, seems to be Dr. Pellizari's favored 
idea, believing that puerperal peritonitis was in most of cases a 
secondary stage of local disease. 

The work of Dr. Braun on uraemic convulsions is divided into ten 
chapters, of which the first two are devoted to an account of the 
symptoms and pathogeny. Eclampsia puerperalis is defined to be an 
acute affection of the motor function of the nervous system, charac- 
terized by insensibility, tonic and clonic spasms, and occurs only as 
an accessory phenomenon of another disease, generally of Bright's 
disease in an acute form, which under certain circumstances, spread- 
ing its toxaemic effects on the nutrition of the brain and whole ner- 
vous system, produces those fearful accidents. The eclampsia gravi- 
darum, according to Dr. Braun, is commonly due to that form of 
blood-poisoning which results from the retention and decomposition 
of urea in the blood, or the retention of the excremential, extractive 
matter of the urine. Another form of eclampsia, presenting some- 
what different symptoms results from the defective elimination of 
carbonic acid, bile, and other matters which in a state of health are 
freely and constantly separated from the blood. There is also a 
phlegmasial variety of eclampsia, known as the cerebral or apoplec- 
tic,, and originating from meningitis, encephalitis intermeningeal 
apoplexy, thrombosis of the longitudinal sinuses, and hypei aemia of 
the brain, spinal cord or medulla oblongata. Eclamptic attacks are 
sometimes very closely simulated by hysterical convulsions. Sudden 
death from hemorrhage is often accompanied with eclampticphenomena. 
Conditions similar to eclampsia are occasionally produced by mineral, 
animal, and vegetable poisons, and the inhalation of carbonic acid, 
and carbonic oxide gases. Dr. Braun, after analyzing the numerous 
views entertained as to the cause of eclampsia, arrives at the con- 
clusion that the eclamptic convulsions of women during pregnancy 
must be considered to be identical with the fits of adults in general, 
that are produced by uraemia in the course of acute Bright's disease. 
This doctrine, which he regards as "an axiom in theory as well as in 
practice," he announced in 1851, about the same time that Frerichs 
published his well known essay on this subject. But from this con- 
fession of Dr. Braun it would be wrong to deduct, that he considered 
Bright's disease as the only cause of genuine eclampsia. When 
speaking of the different forms of eclampsia he himself acknowl- 



271 

edges a phlegmasic, cerebral or apoplectic variety. All he endeavors 
to prove is the frequent connection of eclampsia with Bright's dis- 
ease of the kidneys. Concerning the concomitant oedema, he says : 
Only those oedemata of pregnant women which exist contemporane- 
ously with albumen, fibrin cylindres, and fatty degenerated scales of 
Bellini's epithelium in the urine, have a connection with uraemic 
eclampsia. The oedema of the lower extremities, ascites and hy- 
dramnios, which are not complicated with albuminous urine contain- 
ing fibrin cylindres, are not followed by uraemic eclampsia in preg- 
nancy or labor. The affection of the kidneys with disease cannot 
with certainty be inferred from the appearance of dropsy, as distinct 
causes may, at the same time, or one after the other, produce drop- 
sies. With regard to the cause of uraemic convulsions Dr. Braun 
adopts the theory of Frerichs, who attributes uraemic intoxication 
not to urea but to the presence of carbonate of ammonia in the blood, 
which he supposes to be formed from the urea by the action of some 
ferment. He assures to have detected this salt in the blood, and ex- 
halations in all cases in which the symptoms of uraemia were de- 
veloped. The researches of eminent writers upon this subject, such 
as Litzmann, have shown sufficiently that carbonate ammonia is not 
absolutely necessary for starting uraemic convulsions. Very recently 
Dr. Hammond, Assistant Surgeon U. S. Army, in his article " on the 
injection of urea and other substances into the blood " ( The North 
American Med.-Chir. Review, Vol. I, No. 2, March, 1858), has under- 
taken some experiments, which are decidedly opposed to the views 
advanced by Frerichs. From these experiments he concludes : 1. 
That urea (simple and combined with vesical mucus), carbonate of 
ammonia, and sulphate of potash, when injected into the blood- 
vessels of sound animals, do not cause death. 2. That nitrate of pot- 
ash, when thus introduced, is speedily fatal. 3. That death ensues 
from the injection of any of the foregoing substances into the circu- 
lation of animals whose kidneys have been previously extirpated. 
4. That in neither case does urea, when introduced directly into the 
circulation, undergo conversion into carbonate of ammonia. Judg- 
ing from these experiments, Dr. Hammond thinks that Frerichs's 
theory of uraemic intoxication is erroneous. In neither of the cases in 
which urea was injected into the circulation was any ammonia detected 
in the breath, or vomited matters. Without pretending to question 
the accuracy of Frerichs's statement, he is of the opinion that the 
presence of carbonate of ammonia was accidental. It thus appears, 
from these conflicting statements, that the pathogenesis of this im- 
portant disease is yet far from being satisfactorily established. The 
third and fourth chapters of the work before us treat of the connec- 
tion of labor-pains with eclampsia, and the influence of the latter 
upon the life of the foetus. Dr. Braun thinks that the pains should 
be regarded as the effect rather than the cause of eclampsia ; and he 
asserts positively that fits cannot be produced at will, nor even 
aggravated by exciting pains and increasing their strength. The 
great danger to the life of the foetus our author refers chiefly to the 
presence of carbonate of ammonia in the foetal blood. Chapters five 
and six are taken up with the consideration of the etiology and path- 



272 

ological anatomy of ursemic eclampsia. The following chapters 
treat of diagnosis, prognosis, and treatment of eclampsia and 
Bright's disease. Altogether, Dr. Braun's work will fully repay 
an attentive perusal. We conclude this short analysis by quoting 
the words of the reviewer of the North American Medico- Chirurgical 
Review : " Upon the whole, this work is the most complete and eru- 
dite essay upon the subject of which it treats, that we are acquainted 
with, and we only regret that our limited space prevents us from 
more full}' laying before our readers the peculiar views of its author." 

Dr. Pirrie's paper, read before the Belfast Medical Society, is 
essentially nothing but a reproduction and endorsement of Dr. 
Braun's views on puerperal convulsions. 

Dr. Isham's article on puerperal convulsions is one of the most 
scientific and instructive articles we have met with. It discusses 
the influence of diseases of the kidneys upon the production of 
eclampsia in a way which clearly shows that the author is well 
acquainted with the latest progress in science. Added are some new 
and important observations. 

In a paper read before the Berlin Obstetric Society, Dr. Litzmann 
expresses his opinion that future times would establish the fact that 
eclampsia ought to be considered as a symptom of uraemia with very 
few exceptions. Still, eclampsia is not the only form of uraemic in- 
toxication. Other symptoms of this affection are, amaurosis, coma, 
mania and typhoid fever. The most general cause of uraemia in 
cases of this kind is Bright's disease of the kidneys, i. e., an exudation 
of an albuminous and fibrinous fluid into the urinary ducts, in conse- 
quence of which the excretion of urea and other ingredients of urine 
is checked. It most commonly takes its origin during the latter 
months of pregnancy, owing to a stasis of the venous blood in the 
kidneys. The urine taken from women thus affected shows a con- 
siderable decrease of urea, and very often of lithic acid. It often 
happens that the progress of the disease, as detected by the micro- 
scope, does not correspond with the symptoms during life, and the 
reaction of the system seems to depend more upon the extension than 
upon the intensity of the affection. If a considerable portion of both 
kidneys is affected with the first stage of the disease, the effect upon 
the constitution of the blood is greater than if a smaller portion is in 
a more advanced stage. In the former instance, the excretion of 
urea must be more restricted than in the latter one. This is exem- 
plified by the history of a case, where, with a seemingly far advanced 
degeneration of the kidneys, the excretion of urea was not diminish- 
ed, and, consequently, no uraemic symptoms occurred. 

The second case reported was one of congestion of the kidneys, in 
which severe uraemic symptoms set in, while only very slight traces 
of albumen could be detected in the urine. But a chemical analysis 
proved a considerable decrease of urea during the several attacks ; 
and when the patient began to recover, a larger quantity of urea 
could be detected in the urine. The child which was born with a 
cyanotic tint, died twelve hours after birth. A chemical analysis 
proved the presence of a considerable quantity of urea in his blood. 

Dr. Pesch gives the history of a case of eclampsia, from which he 



273 

concludes that venesection is not useful in all cases of puerperal 
convulsions ; in this instance at least blood-letting seemed to do more 
harm than good, as it was followed not only by a severe collapse, but 
also by an increased intensity of the single fits. Moreover, the arti- 
ficial termination of delivery seemed to have not the least influence 
towards checking the convulsions. Dr. P. proposes the internal use 
of chloroform in similar cases, as its application in this instance was 
doubtless of great benefit. 

The case of Dr. Wegscheider is interesting, inasmuch as it goes to 
show that the convulsions may set in independently of labor-pains — 
a fact often disbelieved, and by eminent authors (Kiwisch). In this 
instance labor-pains were observed only 48 hours after the first con- 
vulsions ; they lasted for six hours, during which time not one fit 
was observed. 

Dr. Paget reports a case of eclampsia, in which the accouchement 
force was successfully performed ; as soon as the child was born, 
the eclamptic attacks ceased spontaneously. The author is in favor 
of early operation in cases of puerperal convulsions. 

Dr. Carville reports the case of a woman who was taken with 
eclamptic attacks in the fifth month of pregnancy. The patient was 
bled repeatedly for four days, when she began to recover. On the 
fifth day a dead foetus was born. Although the legs were remarkably 
oedematous and the urine albuminous, Dr. C. does not believe that 
this was a case of Bright's disease, but he attributes it to some un- 
known occasional influence in connection with the peculiar condition 
of the blood of pregnant women, overtaxed, as it is, with fibrin. 
— rFibrin is just now, with our French brethren, the materia peccans 
for anything that happens to a pregnant woman. — E. N. 

In the cases of puerperal convulsions communicated by Dr. Dale, 
the women had considerable serous effusion into the cellular tissue, 
and in the fatal one, as proved by the post-mortem, into all the vis- 
ceral cavities. In these cases, therefore, it is probable that the con- 
vulsions were produced by the united operation of effusion at the 
base of the brain and the poisoned state of the blood. As regards 
the treatment adopted, the author thinks that bleeding saved the 
lives of the two patients who recovered. In the fatal case the 
patient ought to have been bled more freely ; and it is probable she 
also would have been saved if the feeble pulse (perhaps masked by 
the oedema) had been disregarded. 

Dr. Wellington reports seven cases of puerperal convulsions, and 
remarks, that of all the remedies used — venesection, leeches, cathar- 
tics, anti-spasmodics, rubefacients, etc. — the inhalation of chloroform 
or ether seemed the most efficacious. In two cases it controlled the 
convulsions, while in the others Dr. W. thinks it did good. 

Dr. Chapman gives a few statistics from English books, and pro- 
ceeds to report nine cases of eclampsia of his own. In reading all 
his remarks on the disease in question, we are impressed with the 
antediluvian character of this article. Not a word is mentioned of 
the great discoveries of our times. The author seems to be perfectly 
ignorant of the connection of morbus Brightii and eclampsia. He re- 
jects the use of chloroform in eclampsia, because the two cases in 
18 



274 

which chloroform was given, died. In one of these cases (5) it was 
administered at a time when the case had advanced to such a 
hopeless condition, that Dr. Chapman had to "call in" a third doctor 
"to help him out." The other case (9) seems to have nothing at all 
to do with eclampsia. We recommend Dr. C. to read Dr. Braun's 
treatise on eclampsia parturientium. 

Dr. Moreau recommends the use of elastic stockings (Bourgeaurd's) 
in cases of phlegmasia alba dolens. He has tried and found them 
very useful in a considerable number of cases. They are preferable 
to the common roller-dressing, because the pressure, thus performed, 
is less energetic and still more efficient. 

Dr. Atthill reports a case of mania in a lately confined woman, 
where very large doses of morphia failed to produce sleep or rest. 
He therefore chloroformed the patient, and placed a grain of muriate 
of morphia on her tongue, continued the inhalation of chloroform for 
half an hour, and then gradually withdrew it. By this management 
the desired effect was procured, she continued to sleep and recovered 
her senses perfectly. 

Dr. Lebert has already directed attention to a form of chlorosis, 
peculiar to women in child-bed. He reports another interesting case 
of death from this cause, where no anatomical lesions whatever 
could be detected post-mortem. 

The object of Dr. Coulson's article on secondary affections of the 
joints in puerperal women, is to show that this disease is connected 
with pyaemia. In the large majority of cases, purulent phlebitis of 
the parts originally affected has been observed after death. This 
holds good especially for cases which occur in connection with puer- 
peral fever. The careful observations of M. Tonelld, at the Lying-in- 
Hospital in Paris, place the fact beyond doubt, apd show that, al- 
though these secondary joint-affections, and the general symptoms 
which accompany them, never take place without having been pre- 
ceded fey primary suppuration, purulent phlebitis, and primary sup- 
puration of the cellular tissue do not necessarily give rise to them. 
The pus-poisoning and secondary deposits are an occasional, but not. 
a constant effect of the phlebitis and primary abscesses. Thus in 
two hundred and twenty-two post-mortem examinations of patients 
who died from puerperal fever, M. Tonelle" found suppuration of the 
veins or lymphatics of the uterus in one hundred and thirty-four 
cases ; yet of these, ten cases only furnished examples of secondary 
articular disease. In many cases where pus has not been found in 
the uterine veins or lymphatics, it has been found in other tissues ; 
and the very few cases related where no pus was found, show either 
that the post-mortem examinations were imperfectly conducted, or 
that the temporary secretion of pus might have been fairly inferred 
from the symptoms during life. The presence of vitiated and putrid 
secretions in the uterus does not account for the disease. It is not 
produced by retention of the placenta after abortion. It does not 
occur (unless phlebitis exists) in the form of puerperal fever, which 
is characterized by putrescence and softening of the uterus. It is not 
produced by the ingestion of putrid animal substances into the 
stomach. The disease occasionally occurs in females without any of 



275 

the accompanying- circumstances of the puerperal state. Yet in its 
course, symptoms, and termination, it does not differ from the form 
which occasionally accompanies puerperal fever ; the only modifica- 
tions being those which arise from the presence or absence of the 
puerperal fever itself. The author does not deny the pernicious in- 
fluence of vitiated secretions, while he maintains that all observa- 
tion and analogy establish the doctrine, that, unless these secretions 
excite purulent phlebitis, or give rise to primary deposits of pus in 
some of the tissues, they are not followed by the train of symptoms 
known under the name of pyaemia. 



X. APPENDAGES OP THE FCETUS, EXTRA- 
UTERINE AND MULTIPLE PREGNANCY. 

1. Duhamel, Robin and Mattei, on Hydrops of the Chorial Tufts. — 
Gaz. des Hop. 11 ; 84. 

2. McCaw, J. B., a Case of Uterine Hydatids. — Virginia Jour. XI. 5. 
November. 

3. Maurice, on a Case of Uterine Hydatids. Saint-Etienne: Thealier, 
aine". 8. pp. 10. 1858. 

4. Mayer, Removal of a Mole from the Uterus by Injections of Warm 
Water.— Wiirtemb. Corr. Bl. 16. 

5. Read, W., on the Influence of the Placenta upon the Development of 
the Uterus during Pregnancy. — Americ. Jour. April. — New York 
Jour. Nov. 

6. The Physiology and Treatment of Placenta Proevia. By R. Barnes, 
M.D. London, Churchill. 8. pp. 220. 

7. Lee, R., Clinical Reports of Twenty-one Cases of Uterine Hcemor- 
rhage from Placental Presentation. — Med. Tim. and Gaz. 426. 
Aug. 28. 

8. Curray, R. 0., Case of Placenta Prcevia, etc. Nashville Recorder. 

I. 1. Sept. 

9. Grant, J. H., a Case of Placenta Prcevia. — Charleston Jour. 
March. 

10. Spiegelberg-, 0., Cases of Placenta Prcevia. — Mon.-Schrift f. Ge- 
burtsk. Feb. 

11. Byrne, E. D., a Case of Placenta Prcevia. — Med. Tim. and Gaz. 
May, 22. 

12. Rhoads, a Case of Placenta Prcevia. — Americ. Jour. April. 

13. Marshall Weir, Report of a Case of Placenta Prcevia, in which 
Turning was Successfully Resorted to in Extreme Exhaustion. — 
Lancet. II. 4. Oct. 

14. Garland, E. C, Report of a Case of Placenta Prcevia, in which 
Turning was Successfully Resorted to, Chloroform Given with Ad- 
vantage, and the Child Resuscitated by the "Ready Method." — Lancet. 

II. 5. Nov. 



276 

15. Removal of the Placenta in the Early Months of Pregnancy, by 
Evulsion. (Discussion of the Obstetric Section of the New York 
Academy of Medicine ) — Amer. Monthly. X. 4. Oct. 

16. Gibb, 0. 0., Removal of the Placenta in the Early Months of Preg- 
nancy by Evulsion. — Ibid. X. 6. Dec. 

17. Dubois, P., on Morbid Adherence of the Placenta. — Gaz. des 
Hop. 65. 

18. Vullyamez, Application of the Forceps, Retention and Adherence 
of the Placenta. — Powerful injections of Water Successfully Applied. 
—Ibid. May, 20. 

19. Geoffray (de Montreuil), on Injections of Cold Water into the 
Veins of the Cord in Cases of Adherent Placenta. — Ibid. 16. 

20. Smith, J. D., Adherent Placenta; the Use of Chloroform. — Ogle- 
thorpe Jour. I. 4. Oct. 

21. Hancox, H., on Adhesion of the Placenta. — Brit. Jour. July It. 

22. Jones, J. W., on Adhesion of the Placenta. — Atlanta Jour. March. 

23. Houel. on Adhesion of the Placenta and Membranes with Portions 
of the Foetus. — Gaz. de Paris. 3. 

24. Perroud, a Foetus with Double Placenta. — Gaz. de Lyon, 15. 

25. Logan, A., of Leavenworth Cy., Kansas, Case of Abortion at five 
Months, with a Remarkable Disposition of the Placenta, and the Mem- 
branes of the Ovum ; with Some Remarks thereon. — Cincinnati Ob- 
server. I. 9. Sept. 

26. Thomas, Gaillard T., on Prolapsus of the Funis. (Paper read be- 
fore the New York Academy of Medicine). — New York Jour, of 
Med. IV. 2. March. 

27. Mendenhall, G., a Case of Prolapsus of the Umbilical Cord, Compli- 
cating Labor. — Cincinnati Observer. I. 10. Oct. 

28. Harris, R. P., Case of Fallopian Pregnancy, Resulting in Rupture 
of the Cyst and Terminating in Death. — Americ. Jour. LXIX. 
January. 

29. Johnston, Cr., Case of Extra-uterine Pregnancy; Foetus Extracted 
per Anum, Four Years and Six Weeks after the Completion of Na- 
tural Term. — Americ. Jour. April. 

30. Young, W., of Aurora, 111., a Case of Extraction of the Rones of a 
Foetus from the Peritoneal Cavity. — Chicago Jour. I. 8. Aug. 

31. Lattey, P., Case of Extra-Uterine Pregnancy. — Med. Tim. and 
Gaz. 428. Sept. 11. 

32. Levy, Extra-Uterine Gestation, with Perforation into tlie Rladder. — 
Schmidt's Jahrb. No. 11. 

33. Harrison, G., of Macon, Ga., Medico-Legal Notes of a Case of Ex- 
tra-Uterine Pregnancy. — Southern Jour. XIV. 10. Oct. 

34. Extra-Uterine Pregnancy; its Differential Diagnosis from Peri- 
Uterine Hematocele. (Discussion of the Soc. Anatom.) — Gaz. Hebd. 
V. 26. 

35. Schultze, B., Turin-Birth with Five Extremities Presenting.— Mo- 
natschrift f. Geburtsk. May. 



277 

36. Duval, B., on a Case of Delivery with Twins. — Rev. Ther. du Midi. 

XII. June. 
31. Goldberg, on a Remarkable Case of Twin-Birth. — Oesterr. Zeit- 

schrift f. prakt. Heilk. IV. 39. Sept. 

38. Webb, W., Birth of Triplets; Adhesion of the Placenta; Recovery 
of Mother; Death of the Children on the 2nd and 3d Day. — Lancet, 
I. May. 

39. Marx, on a Case of Birth of Triplets; Diagnosis before Delivery; 
Three Living Children. — Jour, de Bord. — Mon. des Hop. VI. 129„ 

Although Dr. Thomas's plan of managing the funis in cases of pro- 
lapsus has been taught for years past by Dr. Bloxam, in his lectures 
at the Grosvenor Place School of London, it w as not known to the 
profession at large. Therefore Dr. Thomas's re-invention and publi- 
cation of the proceeding, deserves the gratitude of all obstetricians. 
It is a procedure which has already saved many lives, which would 
have been lost, if it had not been for the application of Dr. Thomas's 
plan. The writer of this himself has treated lately a case of pro- 
lapsed funis of the worst kind, viz. : connected with a cross presenta- 
tion, — by placing the patient a la vache. The cord was retained 
perfectly, and the child some time afterwards extracted alive. Of 
course we cannot expect that this proceeding will work so admirably 
in every case, but if only the life of one child should have been saved 
by the method in question, this would be sufficient cause of gratitude 
towards its inventor. 

Dr. McCaw reports a case of uterine hydatids and says : " It is 
difficult to say, whether we should believe in the theory laid down 
by most of pathological anatomists, that these hydatids were inde- 
pendent organisms of law vitality, parasites of the body," etc., (sic ! !) 

Dr. Read's interesting paper was read before the Boston Society for 
Medical Improvement, and is intended to clear up some dark points of 
the theory of the development of the uterus in cases of placenta prsevia. 
The question as yet unsettled is, whether irrespective of the position of 
the placenta upon the uterine walls, the fundus always begins to ex- 
pand before any other portion of the uterus. The arguments brought 
forward in its favor by Doherti, Jacquemier, Murphy, Cazeaux, Ingle- 
by, Ramsbotham, Lee, Blundell, J. Churchill, Meigs, Moreau, and 
many others, are reported and duly criticised. Besides the weak- 
ness of the evidence upon which these authors founded their theory, 
it cannot account for all the phenomena which occur in placenta 
prsevia. Why do some females who have the placenta attached to 
the proper neck of the uterus go their full term, while the majority 
of those who are in the like situation do not go so long ? To give a 
satisfactory and sufficient explanation of these hitherto unexplained 
phenomena, Dr. Read proposes the following theory : the attachment 
of the placenta to any portion of the uterus causes a development at 
that place, which proceeds, pari passu, till the limits of growth in the 
placenta having been reached, the enlargement is continued and kept 
up by the pressure constantly exerted on the uterine walls by the 
growing contents till the time of parturition. In this way, the fact 
that very often, in complete insertion of the placenta, hemorrhage 



278 

does not occur until the full term has been reached, finds a sufficient 
explanation. For by the time that the placenta has passed the 
period of its most rapid growth, the foetal mass has already begun to 
exert its effect upon the uterine walls to enlarge them ; the added 
strength which the thick, firm disc of the placenta gives to the cervi- 
cal portion to resist this distension, is enough to prevent its being 
felt in that direction. It applies also to partial presentations of the 
placenta of every degree, from that in which the os is almost entirely 
covered to that in which the edge only of the placenta is at its mar- 
gin, the latter instance having a marked tendency to early bleeding. 
For just in proportion to the amount of the neck of the uterus covered 
by the placenta is it protected from the distending process to which 
it is exposed during the latter periods of pregnancy, and in just such 
proportion will the hemorrhage appear late or early. Those cases, 
also, where the placenta is on the cervix, in the immediate vicinity 
of the os, but at the same time not overlapping it, instances which do 
not manifest a hemorrhagic tendency, as was to be expected, are 
perfectly accounted for by the same reasoning. 

Dr. Barnes' lectures on placenta prsevia were delivered in 1851, 
before the Medical Society of London. He gives a very philosophical 
view of the nature of placenta praevia ; and while he repudiates 
any attempt to establish dogmatically a new method of treatment, he 
calls in question the propriety of employing empirically the remedial 
measures now generally practiced. Dr. Barnes' treatment of the 
affection is eclectic, each case being treated according to the pecu- 
liar features it may present. 

Dr. Currey reports a case of central location of the placenta. 
After the os was somewhat dilated, Dr. Currey at the time of a severe 
pain, pressed his finger firmly against the placenta, and gradually 
worked it through the spongy mass till he had reached the mem- 
branous surface. The penetration of this gave a free passage to the 
waters ; now the head could be felt presenting ; grasping the abdo- 
men firmly with the left hand, and making pressure upon it, he 
found the head descend at the return, of a pain, and begin to engage 
in the expanded mouth. But the placenta was also pushed forward 
with it, to the great fear of Dr. C. (?) He now administered a full 
dose of select powder of ergot ; a pain soon came on, but as it ex- 
pelled the child, it continued to expel the placenta also, so that one 
half of it fully was now protruded into the vagina. Another strong 
pain passed the child beyond the placenta, and soon expelled it. 

In concluding, Dr. C. says : " My whole course consisted simply in 
endeavoring to check the haemorrhage, by cold applications and re- 
cumbent position, until the favorable time for the laceration of the 
placenta, through which I hoped and was gratified in seeing the 
child safely pass." From this it seems that Dr. C. wanted the child's 
head to pass through the artificial opening in the placenta, and adds, 
he was gratified in seeing it pass. This latter remark is contradic- 
tory to the account of the birth as stated above, whereby it appears 
that the child passed beneath the placenta, leaving it in the vagina 
after it was born, and this is the only course possible. How can Dr. 
C. imagine that a child's head would pass through a small hole 



279 

made by the finger in the placenta, unless the latter was in unusually 
strong marginal connection with the womb by false adhesions ? 
How can any one suppose that such a broad surface as a child's head 
is, would pass through this small artificial opening ? The head will 
always sooner push the placenta before it, and finally pass by it, just 
as it happened in this instance. Moreover, this method of perforat- 
ing the placenta, is not a new one, as Dr. C. seems to suppose. 
Levret, Merriman, Oooch, and Lbwenhardt, proposed to make an 
opening in the placenta, to dilatate it, in order to enable the opera- 
tor's hand to enter through this hole, to turn the child, and extract 
it afterwards. Even this by far more reasonable proposition, has 
not been found worth while to be tried by the profession, from rea- 
sons too obvious to discuss. 

Dr. Spiegelberg reports several cases of placenta prsevia, and 
cautions not to rely too much on plugging the vagina in cases of 
severe haemorrhage from placenta praevia, this applying more par- 
ticularly to the caoutchouc bladder-plug (colpeurynter). In some of 
the cases reported, the blood passed by the plug, or collected above 
it in that large space of the laquear vaginae which remained between 
the plug and the uterus. 

The discussion of the Obstetric Section of the New York Academy 
of Medicine on removal of the placenta in cases of abortion, was 
opened by Dr. Gardner with the remark, that in cases of retained 
placenta, after a miscarriage, he introduced a small pair of polypus- 
forceps, and withdrew the afterbirth. In the progress of the discus- 
sion, the use of instruments in similar instances, was generally 
rejected, because ergot, the tampon, or the operator's hand, were con- 
sidered as remedies answering all purposes. Dr. Barker's method, 
which has been successfully applied by the writer of this many 
times, is the following : a compressed sponge of the proper size is 
introduced into the cervix, in order to stop the bleeding, and excite 
uterine action, so that the ovum, or placenta, is completely detached. 
In conjunction with this, an enema of the oil of turpentine (with 
starch) is thrown into tlie rectum, and retained as long as possible, 
repeating it as soon as it comes away. The turpentine in this way 
acts as a hemostatic and an oxytocic. 

Dr. Gibbs reports two cases in which only part of the ovum had 
been detached, while the remaining portions caused a violent 
haemorrhage. All the styptic remedies had been tried in vain, and 
as the portion retained in the uterus could not be reached with the 
finger, Dr. Carey's decidual separator was introduced into the womb, 
and the membranes removed, whereupon the haemorrhage stopped im- 
mediately. Both cases are full of interest, and a fit supplement to 
the discussion in the Academy just mentioned. 

Dr. Dubois remarks that the adherence of the placenta was per- 
fect or imperfect ; that in the former instance, the after-birth is 
simply retained, while partial adherence is followed by haemorrhage, 
because the utero-placentar circulation goes on undisturbed, and the 
tendency of the blood rushing towards the entire placenta is un- 
checked, from which place the blood escapes freely out of the opened 
blood-vessels. The time allowed to wait for the expulsion of the 



280 

placenta by the author is one or one hour and a half, after the birth 
of the child. 

Dr. Logan's article on a case of abortion, etc., is the choicest piece 
of self-mystification on record, bearing full evidence of the fact, that 
Kansas is greatly in want of literary and scientific immigration. Dr. 
Logan attended a five month's abortion case, and after removing the 
ovum, he " found something he had never seen before, the placenta 
and the greater part of the chord presenting the curious anomaly of 
being entirely external, separate, and distinct from the membranous 
enclosure of the child. The cord was given off about its centre, and 
after proceeding a distance of sixteen inches, it entered the chorion 
and amnion by a distinct perforation. The decidua vera not only 
lined the placenta, but presented the appearance of a cellular mem- 
brane, with the fleshy particles of the placenta deposited within its 
mesches, as if it were the sole agent in its formation." Now from 
this description, it is as clear as daylight, that the doctor, while re- 
moving the ovum, had severed the foetal from the uterine portions of 
the placenta, as it may easily happen with a four or five month's ovum. 
" This is but a single case," says our author, " but the fact is here ; 
a placenta has been in one case perfectly and apparently, naturally 
formed, without any possible communication with, or influence from 
the chorion." " Regarding the decidua as an exudation of coagulable 
lymph" (!) Dr. Logan proceeds to revive Hunter's dead theory of 
placental formation. 

Dr. Thomas laid before the New York Academy a plan of treatment 
for prolapsed funis which he had proposed in a course of lectures on 
obstetrics, delivered in the University Medical College of this city 
two years ago, and which he has since taught, but had waited for 
clinical evidence before bringing it before the profession. The causes 
6f the great persistence of this accident, said he (whatever may have 
originally produced it), may be stated as these : 1st, the slippery 
nature of the funis ; and 2nd, the inclined direction of the uterine 
axis, which being in a line running from the umbilicus, or a little 
above it, to the coccyx, favors very much the tendency of the slippery 
part to roll outwards. These conditions he had thought might not 
only be overcome, but might themselves be rendered serviceable in 
effecting reduction, by inverting the uterine axis by placing the 
woman on her hands and knees, in the posture employed by surgeons 
in operating on the uterus and vagina. He had now tried this 
method in two cases, and reported as follows : 

The first was a robust Irish woman, a multipara, who was sitting 
by her bed when the waters broke, and brought down a loop of the 
cord. It had been returned to the uterus repeatedly by the phy- 
sician in attendance, and the porte cordon recommended by Dr. 
Ramsbotham was used to retain it. At each successive pain, how- 
ever, it again prolapsed, and when he saw the case it was suffering 
from pressure by the descending head. He repeated the attempts 
which had been made by returning the cord, but, like them, his were 
unavailing. Placing the woman on her knees, with her face and 
chest resting upon the bed, he now proceeded to return the cord, 
when he discovered that without his aid it had retreated — and the 
labor proceeded without difficulty — a living child being soon born. 



281 

To the second case he was called before the waters had broken, 
and in the unruptured bag he detected the cord in large amount. As 
the os was fully dilated he ruptured the bag, and instantly the cord 
descended, and appeared to fill the vagina. Pushing it up beyond 
the head in an interval, he now waited to see whether it could be 
retained there during the -next pain, but a large loop was at once 
forced down, and this occurred two or three times as the result of 
this attempt. The woman was now placed in position, and although 
the cord did not, as in the first case, reduce itself, no part of it once 
pushed up returned, and the labor safely concluded. 

In both these cases the woman was allowed to choose her position 
after the head had fully descended, and occupied the pelvic cavity. 

The author, in concluding, expressed his regrets that the plan pro- 
posed should not have been more fully supported by clinical facts, 
and stated as his reasons for bringing it forward in its present con- 
dition, the conviction which he felt that the simplicity of the method 
would at once recommend it for trial, and his desire cordially to 
invite the profession to test it, and give it its proper stand, whether 
of credit or of discredit, among the means at present at our command 
in treating this class of cases. 

The rules of treatment pointed out were these : 

1. If the cord is detected before the waters have broken, let no 
manual assistance be offered, but place the woman at once in posi- 
tion, and trust to this for its return to the uterus. 

2. Should the waters have flowed away, and left the cord below 
the head, place the woman in position, and push it up with the hand 
if practicable, or with a porte cordon, consisting of a gum elastic 
catheter, with a tape passed through it, if not so — 

3. Let no manipulations be commenced until the woman be placed 
in position. 

Dr. Mendenhall reports a case of prolapsus of the umbilical cord, 
head presenting, which was successfully treated by Dr. Thomas' 
method. 

Dr. Levy remarks, that the number of cases recorded in our litera- 
ture as so-called vesical pregnancy, is very limited. The first instance 
of this kind was observed by Dr. Ebersbach, in 1114 (Ephemer. natur. 
cur. cent. 5 obs. 20). Meissner (Frauenkrankheiten Bd. 3) mentions 
only 6 more cases, and Levieux (Bullet, des sciences m,4d., 1822) 
reports some instances where particles of foetal bones had entered 
into the composition of vesical stones in the form of nuclei. 

Dr. Levy's patient was 54 years old, and had given birth to 3 chil- 
dren. When 31 years old, she again thought she was in the family 
way. Between the 2nd and 3rd month she began to flood consider- 
ably without any ostensible cause, and she was of opinion that she 
had miscarried. After the lapse of one month the bleeding discon- 
tinued, and the menses did not come back any more. The woman 
began to grow very stout, the mammae increased considerably in 
size, and when she was gone about half of her time, as she thought, 
she fancied that she felt the quickening. Altogether, her condition 
was favorable ; nothing out of the way was observed with regard to 
the abdomen ; the breasts contained milk, and the feet were some- 



282 

•what cedematous. When she calculated to be at her full term, she 
suddenly experienced a movement in the lower abdomen, just so as 
if the foetus had turned round ; this was accompanied by a severe 
chill, which repeated several times. A few days afterwards energetic 
labor-pains set in, which, however, soon stopped entirely, when a 
short hemorrhage occurred. The attending midwife decided to have 
felt something like the shape of a presenting head, but all was not 
right. Instead of uterine contractions, a violent pain was now felt 
in the lowest part of the stomach, right above the symphysis pubis. 
This painful sensation went away gradually, while the abdominal 
tumor grew smaller and harder ; the menses reappeared, and the 
patient recovered so entirely that she began to resume her ordinary 
occupations. 

Early in 1854, %. e., 15 years afterwards, the patient was taken 
with symptoms of biliousness, with pains in the pubic region, com- 
bined with constant inclination to pass water. Notwithstanding all 
this her general health remained in pretty fair condition, and it was 
only towards the end of December that the urine began to appear 
thick and milky, with a disagreeable smell, till at last it became 
puriform. The sensation of bearing down now increased consider- 
ably, when, without the least difficulty, a portion of a foetal bone 
was passed through the urethra. From this time to April, 1855, 
three more pieces were discharged in the same way. The patient 
was now very pale and lean, still comparatively healthy. Up to 
February 1, 1856, fifteen large and numerous smaller bones were 
passed, the urine had a very foetid smell, and contained besides a 
good deal of pus, a considerable quantity of minute bony particles. 
At last the strength of the patient gave away, and she died on May 
29, 1856. 

Post-mortem examination. — No trace of peritonitis. After the in- 
testines were removed, a hard, uneven tumor, covered with a serous 
membrane, was detected ; it was coherent with the spinal column, 
and attached to the rectum. This tumor was of the size of a child's 
head, was situated exactly behind the symphysis pubis, and contain- 
ed smaller and larger osseous plates. The uterus, of normal size, was 
pushed towards the left side. The extra-uterine sac, which contain- 
ed the greatest portions of the bones, was located towards the right 
side, between uterus and rectum. In front it communicated freely 
with the bladder and backwards into the rectum. The bladder was 
filled with numerous foetal bones, of different sizes, the larger ones 
being incrusted to a considerable extent, while the walls of the 
bladder were considerably hypertrophied. 

The author, in ventilating the question, whether, under similar cir- 
cumstances, an operation should be resorted to, remarks, that the 
high operation for stone had been performed for the said purpose, but 
always with unfavorable result, and he, therefore, proposes to try 
urethrotomy as a less dangerous operation. The very interesting 
article is concluded with a short analysis of Dr. Josephi's case of 
vesical pregnancy, published in a thesis on extra-uterine pregnancy, 
Rostock, 1803. In this instance cystotomia alta was performed, but 
the patient died 3 days after the operation. 



283 

The remarkable feature in Dr. Harrison's case of extra-uterine 
pregnancy, was the presence of two ligaments attached to the pla- 
centa, independent of the cord ; one about six inches long, connect- 
ing with the transverse colon ; the other about four, connecting with 
the body, just above the point of the ileum. 

The parts presenting after the rupture of the membranes in Dr. 
Duval's case were, nates and hand of one foetus ; elbow and foot of 
the other. Our author applied the forceps to the nates and delivered 
the child without difficulty, whereupon he seized the foot of the other 
child and extracted it without difficulty. Both children were born 
alive and continued in good health. 

In the case published by Dr. Goldberg, a woman was delivered 
naturally of a healthy child, when ten minutes afterwards a second 
apparently five months' foetus was extracted. It had the appearance 
of" an alcohol preparation ; it was compressed from both sides, thus 
representing only the silhouette of a foetus. 



XL REMEDIES. 

1. Lee, R., History of a Case in which Death was Quickly Produced by 
the Inhalation of Two Drachms of Chloroform in the First Stage of 
Natural Labor. — Med. Tim. and Gaz. 436. Nov., 6. 

2. Rigby, E., on the Use of Chloroform in Natural Labor. — Ibid. 429. 
Sept. 18. 

3. Williamson, W., Chloroform in Midwifery. — Ibid. 432. Oct. 9. 

4. Cotting, B. E., of Roxbury, the Extent to which Ancesthetic Agents 
should be Used in Midwifery. 

5. Debussaux, A. N., on the Employment of Chloroform in Cases of 
Hysteria, Thesis (in French). Strassbourg, Bergen-Levrault. 4. 

6. Afflick, J. G., Observations on the Use of Ergot as a Haemostatic and 
Abortive. — Transactions of the Belmont Med. Soc. 

7. Fauvel, Peculiar Effect of Ergot during Labor. — Rev. M£d. July 15. 

8. Heslop, T. P., Suggestions relative to the Employment of Tincture 
of the Sesquichlorid of Iron in Puerperal Peritonitis, Iritis and 
Allied Disorders. — Dubl. Jour. LI. August. 

9. Bonfils, on the Use of Opium and Turpentine in Puerperal Fever. — 
Gaz. des Hop. 11. 

10. Vedder, J. H., Veratrum Viride in Cases of Puerperal Fever. — 
Americ. Monthly. January. 

11. Clarke, A. B., of Holyoke, Mass., on the Treatment of Puerperal 
Mania by Veratrum Viride. — Brit. Jour. LIX. 12. Oct. 

12. Gros, L., on the Use of Pepsine in Cases of Vomitus Gravidarum. 
Bull, de The>. Feb. 

13. Dezou, Vomitus Gravidarum, Treated by Cold Water. — Rev. de 
Thdr. 9. 

14. Darsch, E., Yarrow (Achillea Millefolium). — Peninsular Jour. I. 
1. Oct. 



284 

15. Ronzier-Joly, A., on the Suppression of the Lochial Discharge in 
Puerperal Disease; a Simple Remedy to Reestablish it. — Bull, de The"r. 
LV. 8. 

16. Beauvais, Uva Ursi as an Obstetrical Agent. — Bull, de TheY. 
Jan. 30. 

IT. Fenner, E. D., Remedy for Dysmenorrhea and Consequent Sterili- 
ty. — New Orleans Med. News. July. 

18. Barker, 0. W., of Omega, Texas, Remedy for Dysmenorrhcea. — 
Ibid. Nov. 

19. Merrill, A. P., of Memphis, Tenn., Dysmenorrhoea Cured by Stram- 
monium. — Ibid. Oct. 

20. Lobach, Semen Cardui Marice and Cardui Benedicti in Cases of 
Uterine Hemorrhage. — Jour, de Brox. June. 

21. Williams, H. L., Port Wine Enemata as a Substitute for Trans- 
fusion of Blood. — Brit. Jour. Sept. 4. 

22. Bonafond, on the Application of Solid Caustics in Diseases of the 
Womb — Bull, de Ther. LIV. May. 

23. Aran, Laudanum Dressings in Painful Affections of the Uterus. — 
Ibid. LIII. 

24. Tilt, E. J., on the Right Use of Sedatives in Diseases of the Womb, 
and in Morbid Menstruation. — Lancet. July. 

25. Parks, L., on the Use of Potassa com Calce in Uterine Disease. — 
Boston Jour. LIX. 9. 

26. Joachim, W., on the Use of Belladonna in Neuralgia Uteri. — 
Ungar. Zeitschrift. IX. 9. 

2T. Aran, F., on Aloes Enemata in Uterine Catarrh. — Bull, de Ther. 
LIV. March. 

28. Caby, E., on the Use of Sous-Nitrate of Bismuth in the Treatment 
of Leucorrhoza. — Ibid. Sept. 

29. Lecointe, Tanninglycerol in Vaginitis. — Ibid. June. 

30. Bernard, M. Ch., on the Treatment of Chronic Engorgement by the 
Ointment of Chlorjodide of Mercury. — Gaz. Hebd. May, 21. N. 
Amer. Review. Sept. 

31. Storer, H. F., Caustic Potash as an Application to the Interior of 
the Uterus. — Boston Jour. LIX. 11. Oct. 

32. Aveling, J. H., Gentian Tents in Partial Occlusion of the Uterine 
Neck. — Med. Tim. and Gaz. June, 26. 

33. Hartmann, on Successful Treatment of Pruritus Vulva; by a Strong 
Decoction of HeUeborus Alhus, Locally Applied. — Annal. de 
Roulers. 21. 

34. Imbert-Goubeyre, on the Use of Arsenic in Pruritus Vulvae. — 
Annal. de Flaudre. 21. 

35. Macd, on the Use of Mineral Waters in Female Diseases (in 
French). Mortelimar, Bourron, 8. pp. 8. 

36. Basret, on the Use of Cold Water in Chlorosis.— L'Union. 39. 

37. Villemin, A., Vichy-Water in Chronic Diseases of the Womb. — 
Gaz. de Paris. 10. 



285 

38. Brack, A. T., on the Use of Driburg Springs in Diseases of Preg- 
nant Women. — Mon.-Schrift f. Geburtsk. XI. April. 

39. Fleckles, on the Use of Carlsbad-Waters in Diseases of the Womb. 
— Schmidt's Jahrb. June. 

Dr. Lee was fortunate enough to ferret out at last a case, where 
the administration of chlorofrom during labor was followed by sud- 
den death. The husband of the patient had administered about two 
drachms of chloroform, when she threw herself violently back, gave 
a gasp or two, a slight gurgle was heard in her throat, and respira- 
tion and the pulse instantly ceased. This fact was communicated to 
the author by Dr. John Campbell of Langs. No post-mortem exam- 
ination was made. — We leave it to the judgment of our readers if 
they will be inclined to take this case as one of death from chloro- 
form. The circumstances connected with the management of the 
chloroform, the small dose administered, the source from which the 
communication emanates, the want of a post-mortem examination are 
all circumstances, which must be taken into consideration so as to 
guide our judgment. But even suppose this and some few other 
women had really died from the use of chloroform ? What does this 
prove against the remedy? Nothing but the often repeated advice, 
to be cautious with this drug. If we hear of but very few cases of 
death from chloroform among women in labor, this is owing to the 
fact that the number of parturient women to whom chloroform is 
given, is comparatively small, when compared with the number of 
persons chloroformed under other circumstances. — E. N. 

Dr. Rigby is of opinion, that chloroform, when judiciously admin- 
istered, has a more favorable influence as regards the patient's re- 
covery after a severe labor, than when it has not been used. 

Dr. Williamson looks upon chloroform as so great a boon in (almost 
all) midwifery cases, that he would no more think of attending a pa- 
tient in labor without having chloroform beside him, than he would 
think of not having a catheter in his pocket. 

Dr. Cotting prefers ether to chloroform, because he thinks it to be 
less dangerous for the life of the patient. The conclusions to which 
he comes from its administration in several hundred cases of labor, 
are as follows : 

1. In ordinary cases of midwifery, while ether may be allowed in 
moderation, when importunately demanded by the patient, it is quite 
as well in the long run, to say the least, to let normal, uncomplicated 
labors proceed uninterfered with. 2. In painful, laborious, or com- 
plicated labors, and in cases of great tenderness or great rigidity of 
the organs, of extraordinary susceptibility to pain, and where there 
is great nervous irritation, or undue apprehension of danger, ether, 
if favorably received, should be used to the extent of overcoming the 
abnormal condition and suffering. 3. In cases requiring manual or 
instrumental interference, ether should be used to the same extent, 
and upon the same general principles as in other operations. 4. In 
puerperal convulsions especially in those having the characteristics 
of ursemic eclampsia, ether should be given as soon as there are in- 



286 

dications of an approaching fit, and be continued if seemingly effica- 
cious, until the paroxysm has subsided, and quiet sleep is induced ; 
or until other medicine, if desirable, can be swallowed — care being 
taken to allow a sufficiently large quantity of pure air, and not to 
continue the ether if coma supervene. 

According to the experience of Dr. Afflick, not only does the 
ergot act well as a haemostatic previously to delivery, but it pos- 
sesses also "a supreme power in the control of post-parturient hem- 
orrhages." Whenever the system becomes fully imbued with the ergot, 
his observations confirm him in the opinion, that there is little to be 
dreaded from the occurrence of bleeding. He thinks that its dangers 
to the life of the child are less, than is generally believed by the pro- 
fession. 

Dr. Heslop having seen good .results from the administration of 
sesquichlor. of iron in epidemic diphteritic affections of the mouth 
and throat, and being dissatisfied with the discussion of the Paris 
Academy of Medicine on puerperal fever, for not having agreed upon 
a prescription for the cure of said affection he proposes to try the tinct. 
of sesquichlorid of iron, and the local application of dilut. muriatic 
acid in puerperal peritonitis. "So far as Dr. H. knows, obstetricians 
have never made an ocular examination of the walls of the vagina 
in puerperal fevers." The writer begs leave to inform Dr. H. that ob- 
stetricians are in the habit of inspecting the vagina, and most thor- 
oughly too. Moreover, the writer can inform Dr. H. that obstetricians 
do "treat the vagina with as little ceremony as the fauces," applying 
solid caustics, acids, and camphorized ether to the frequently enor- 
mous ulcerations, in cases of puerperal fever. For puerperal fever 
in general, we have not, and will never have a panacea, but there is 
a species of the fever, viz.: the diphteritic form, seizing almost ex- 
clusively upon the mucous membranes of the system, in which the 
use of perchloride of iron may be reasonably tried. 

Dr. Bonfils reports that Dr. Trousseau had treated several cases 
of puerperal peritonitis, oophoritis, etc., by large doses of opium (5 
to 10 cgrm. in a day), injections with the oil of turpentine (oil of 
turpent. 10 to 30 grm ; 1 yolk of egg, water 100 grm., with some 
mucilage, twice a day), and the oil administered by the mouth in 
capsules (6 grm. a day). 

Dr. Gros reports seven cases, partially from his own experience, 
partially from that of other practitioners, where the administration 
of pepsine cured the vomiting of pregnant women, in some instances 
where all other remedies had failed to make the slightest impression 
on the disease. Far from advising its application as a general rule, 
Dr. G. recommends it for all those cases where the stomach has par- 
ticipated actually in the morbid condition, be it by an alteration of 
the secretory activity, or in consequence of its being constantly 
called into unnatural activity. 

Dr. Dezou recommends in cases of obstinate vomiting to apply a 
wet towel upon the epigastrium, to be changed every five minutes 
until the cure is completed. 

Dr. Darsch reports some cases of successful application of the herb 
of Millefolium for promoting the menstrual flux. 



287 

Dr. Ronzier-Joly recommends the same remedy for reestablishing 
the lochial discharge in cases of suppression in puerperal diseases. 

Dr. Bouvai3 has successfully applied the folia uvae ursi in cases 
of atonic labor pains, and in hemorrhages from this same cause. 

Dr. Fenner states that he has used for some years in the treatment 
of dysmenorrhoea with great success the following mixture, original- 
ly recommended by Dr. Falk of London : 

R. — Gum. Guaiac, §i. ; Balsam. Canadens, S viii. ; 01. Sassafras, 
3ii.; Merc. Corros. Sublimat, 9i.; Spir. Vin. Rectif., |viii. 

"Dissolve the guaiac and balsam in one-half the spirit, and the 
corrosive sublimate in the other. Let the guajac and balsam digest 
for several days ; then pour off the clear liquor, mix with the subli- 
mate, and add the oil. Dose. — Ten or twenty drops night and morn- 
ing in a glass of wine or water, pro re nata." 

This was called by Dr. Falk " Tinctura antacrida." Dr. Fenner 
says that he usually directs the patient to begin a day or two before 
the expected period, and take twenty-five drops in a infusion of sage 
or sweetened water, night and morning, until the discharge is estab- 
lished ; then cease till the next period. In obstinate cases, the medi- 
cine should be commenced a week or ten days before the period ; 
and if the pain appears, the medicine should be taken every four or 
six hours till relieved. Dr. Fenner has known immediate relief to 
be given by a single dose taken in the paroxysm. In very violent 
cases, in which the pain was excruciating, causing shrieks or even 
violent convulsions, he has successfully applied the following : — R. 
— Spirit, camphor, 5iii-; chloroform, 3ii-; tinct. opii., 5i. M. S. — A 
tcaspoonful in sweetened water once an hour till relieved. 

Dr. Barker proposes the following remed}' for dysmenorrhoea: — 
R. — Gumm. guajac, §i.; Potass Nitr., 3i.; Flor. Sulphur, 3i- To 
be well ground in a mortar and put into one pint of brandy or good 
whiskey, and after standing a few days, to be taken twice a day one 
tablespoonful. For retention and suppression of the menstrua the 
following is recommended : — R. — 01. Terebinth, §i.; 01. Sassafras, 
3$ss.; Spir. Vini. rectif., §viii. M. S. — To be taken in tea, in doses of 
3i. 

Dr. Merrill has successfully applied the extract of Strammo- 
nium in a case of intractable dysmenorrhoea. He advises to begin 
with one grain doses every third hour, ten days before the expected 
time, and to diminish the dose in case of beginning narcotism. 

Dr. Lobach recommends a remedy (before the Med.-Physiol. Soc. 
of Wiirzburg) which had been almost forgotten, if it was not for the 
apostles of Rademaeher, who make use of the semen cardui in cases 
of abdominal plethora and its consequences. Dr. L.'s experience 
goes to prove that it is a sure remedy in uterine hemorrhage, even 
when all other means have failed, but mostly in the flooding from 
a stasis in the circulation of the venae portarum. The dose is from 
2 to 13 drops of the tincture every half or third hour. 

Dr. Williams recommends enemata of port wine in case of post- 
partum hemorrhage, and records a case in which he resorted to it 
successfully. The patient was in the most alarming state of prostra- 
tion, pulseless at the wrist, with cold extremities, &c. Dr. W. com- 



288 

menced by administering four ounces of port wine with twenty drops 
of tincture of opium. The patient speedily manifested signs of im- 
provement. In half an hour he repeated the enema with marked ad- 
vantage, and the patient was soon out of danger. 

The local application of sedatives, though very extensively in use 
as a local remedy in the various forms of pain in other localities of 
the system, is not sufficiently followed in the treatment of diseases 
of women. Dr. Tilt, therefore, proposes to show in this article, what 
good results may be obtained by application of narcotics to the fe- 
male organs. In treating neuralgic affections of the womb, ovaries, 
abdomen, etc., the source of the disease, often lying in a slight ulcera- 
tion has to be removed first, and afterwards, or combined with surgi- 
cal treatment, the local use of anesthetics is followed by very satis- 
factory results. The use of sedatives in such cases paves the way to 
a more rapid cure, especially when several remedies are combined. 
For this purpose, Dr. Tilt orders a camphorated liniment, to four 
ounces of which he adds half an ounce of laudanum, and two drachms 
of tincture of aconite. This has to be rubbed carefully for five min- 
utes on the lower part of the abdomen, or on the sacral region. 
Upon this, a wadding poultice has to be applied and kept in place by 
a piece of oil-silk, sufficiently larire to wrap round the loins and fold 
over in front. Should this be ineffectual, sedatives by the rectum are 
prescribed. Such measures are generally found successful ; but some- 
times the patient will not or cannot retain the medicated fluid, and 
narcoting suppositories are objected to, or else the neuralgia may be 
too severe to yield to the treatment. In a case of this kind, Dr. Tilt 
placed one grain of acetate of morphine in a little cotton wool, folded 
it up, tied a piece of twine round it, and carefully applied it close to 
the neck of the womb. This was withdrawn by pulling at the piece 
of twine, at the end of twenty-four hours. Three days afterwards 
two grains of morphine salt were applied in the same way ; and four 
days afterwards three grains. This medication had a really wonder- 
ful influence upon the neuralgic disease, so that the lady affected, 
who for months had been confined to bed, was now able to sit up- 
right for several hours, and was not overfatigued by a two hours' 
drive, and in a few weeks she was able to leave for the seaside. 
This treatment was always found successful in cases of uterine neu- 
ralgia. The cotton-wool charged with morphine, may be applied 
without using the speculum. If the forefinger of the right hand be 
introduced into the vagina, along this finger the left hand can easily 
glide the forceps armed with the cotton-wool, until the neck of the 
womb is reached. When possible, this application is renewed every 
second day. Dr. Aran has extensively followed the same idea ; his 
plan is to let fall one or two drachms of laudanum into the vagina 
per speculum, fixing the fluid in the vicinity of the womb by a table- 
spoonful of powdered starch. 

Dr. Parks's article was prepared with the intention to prove that 
the application of potassa c. calce outside and inside the cervix, if 
made with circumspection, need not do injury. Added, is a table 
showing the character and result of 31 cases in which this treatment 
was applied. The average number, to a case, of applications to, and 



289 

insertions within cervix uteri, of caustic potash, with or without 
lime, was 4 ; the average number, to a case of applications to the exte- 
rior of the cervix uteri of potassa cam calce, was S~j. In one case 
the lesion was not satisfactorily made out. There was one case of 
abrasion alone ; one of simple congestion ; and one of probable uterine 
catarrh. In all the rest (34) there was more or less of hypertrophy 
or engorgement ; in the removal of which lesions, the potash seemed 
to be most often useful. Only in one case (8) an injury is reported, 
perhaps depending from the application of this caustic, viz : inflam- 
matory symptoms, with subsequent discharge of pus per rectum ; in 
all the rest no injury is recorded. The treatment which Dr. Parks 
endeavors to sustain, is the making of one or more issues on the 
neck of the womb, the aggregate area of which issues is never to ex- 
ceed the space*which can be covered by a three-cent piece ; bearing 
in mind that the diameter of the issue is usually about twice that 0$ 
the cylinder »f caustic. The contact of the caustic with the lining 
tissue, is usually continued from half a minute to a minute. The pot- 
ash is always neutralized with vinegar before withdrawing the spe- 
culum. The potassa cum calce cylinders used by Dr. P., are those 
of Bennet, made by Squier of London. 

In conclusion, a belief is expressed that, in hypertrophy and en- 
gorgement of long standing, the potash treatment is more effectual 
and rapid than the milder caustics. 

Dr. Aran strongly advocates the use of aloe injections for the cure 
of uterine catarrh, ift administers every day or every other, ac- 
cording to the effect produced, first an erema of mere tepid water, 
and then one of the following composition : Aloes, castile soap aa. 
gr. 75 ad. gr. 150, boiling water §iii. 

Dr. Gaby recommends the bismuthum nitricum : 1. For simple vul- 
vitis of small girls. 2. For vaginal leucorrhea. 3. For a form of 
whites, generally embracing vagina, vulva and urethra, which in 
most cases is of a specific nature. The powder is to be applied in 
substance over the affected parts, and with the aid of the speculum, 
when the disease is in the deeper portions of the vagina. Dr. G. 
strongly recommends this remedy as a very efficient one. 

Dr. Lecointe recommends to apply a tampon of cotton, covered 
with equal parts of glycerine and tannin to the vagina per speculum, 
in cases of vaginitis. After the first applications, the discharge gen- 
erally increases considerably, and disappears soon afterwards. 

The formula of chloroiodide of mercury used by Dr. Bernard for the 
treatment of uterine infarct is the following : — Take one part of iodine 
and two parts of calomel ; reduce the calomel to a coarse powder, 
and introduce it into a matrass, heat it gently while stirring it, until 
it commences to sublimate, then add iodine in small portions, and the 
combination takes place. For application to the uterus, from 50 to 
75 centigrammes of this salt are mixed with 60 grammes of fat. M. 
Rochard recommended the use of this ointment only in cases of sim- 
ple and subacute engorgement showing a tendency to become chron- 
ic. It has been applied in the following manner : — The neck of the 
uterus brought completely into view by means of a trivalve specu- 
lum, is cleared of the mucous covering it, with charpie or wadding, 
19 



290 

or with a tampon soaked in glycerine, and applied the day before to 
the cervix. On the other hand a moderately thick pledget of charpie 
of a little larger dimensions than the cervix, is prepared, and its 
centre covered by a thin layer of the ointment, so that its borders 
remaining dry may defend the vaginal mucous membrane from con- 
tact with the remedy which would otherwise occasion inflammation. 
Then the pledget is carried up to the neck, either with the dressing 
forceps or by means of a wooden tube, one extremity of which is pro- 
portionate in dimensions to the cervix uteri, and in which slides a 
stopper which' applies the pledget exactly to the organ. This done 
the vagina is filled with balls of wadding, and the speculum is with- 
drawn. Care has to be taken not to cram the vagina, as it would 
occasion unnecessary inconvenience and pain to the patient. 

Six or seven hours after the application of the ointtnent, the differ- 
ent parts of the dressing are removed and the cervix is laid bare, 
which, on examination with the speculum, is always found covered 
with an albuminous exudation. From a number of five observations 
reported by M. Bernard, we take the following as a sample : Case 
IV. — Old engorgement, which had disappeared after injections of 
carbonic acid, but has returned in the last two months. Cervix 
round, smooth, but hard, not voluminous, and directed backward. 
Applications on the 7th and 21st of September and 9th of October. 
On this day the engorgement was much diminished, also the redness 
and anteversion. On the 18th the patient went out, feeling very 
well. In all the cases reported the amelioration was obvious and 
rapid. It is well to know that the application of the ointment pro- 
duces, for some hours afterwards, more or less acute pain, which 
lasts from twelve to fourteen hours with intensity. The whitish ex- 
udation, which was mentioned above, is generally formed at the end 
of five, six, or seven hours. The process of elimination, the cicatri- 
zation of the wound consecutive to the separation of the eschar, and 
the resolution of the concomitant inflammatory tumefaction requires 
about eight to ten days. It is, therefore, advisable generally to 
observe this interval between two applications. * 

Dr. Bruck remarks, that the Driburg Springs were generally well 
born by patients, even if they are subject to organic diseases or 
great irritability of the respiratory organs, owing to the small per- 
centage of iron (0.85 grains in 16 ounces), and the unusually large 
amount of carbonic acid. This is the reason why women, even in the 
first months of pregnancy,, may safely undergo a treatment with 
Driburg waters in cases of far advanced anaemia, while it was generally 
believed that a thorough mineral (iron) water treatment would 
invariably induce abortus. Dr. Bruck, at least, has successfully 
treated pregnant women with Driburg waters, and has seen that 
they had a good influence upon the foetus. A lady, 30 years of age, 
was delivered of a microcephalic child 10 years ago. In her second 
pregnancy she bathed at Driburg, and gave birth to a strong, well- 
formed child. The third and fifth child were microcephali ; at both 
these times she did not use Driburg. During the fourth gestation 
she bathed at Driburg, and had a perfectly healthy child. 

Dr. Fleckles has applied the thermal waters of Carlsbad ('Bohemia) 



291 

successfully in functional derangements, hypertrophies, and fibroid 
tumors of the womb. Disturbances of the menstrual flux are bene- 
fited by the use of these waters, when they depend from uterine 
hypertrophy, combined with abdominal plethora. Fluor albus is 
cured by the use of this water, when it is caused by a disturbed 
state of health, be it of a scrofulous, gouty, or of a hemorrhoidal 
nature. Ovarian tumors lessen in size after a protracted use of the 
water. Disorders coincident with the change of life find a ready 
relief in Carlsbad. 

[The writer can only endorse Dr. Fleckles' praise of this therapeu- 
tical agent for the cure of uterine disease. The water imported from 
Germany in stone bottles is almost as efficient as that taken fresh 
from the spring. I am constantly in the habit of prescribing it for 
patients affected with chronic metritis and hypertrophy, and I know 
of no remedy which is more certain to remove uterine congestion, 
especially in those numerous cases which are combined with a torpid 
action of the liver. — E. N.] 



XII. OBSTETRICAL OPERATIONS. 

1. Meissner, F. L., Statistics of Operative Midwifery. — Monatschrift f. 
Geburtsk. IX. pp. 19—12. 

2. Meissner, F. L., Obstetric Resources of an Accoucheur in those cases 
of Contracted Pelvis, where a Full Grown Child can not be Born, 
unless Diminished in Size (a historical sketch of the different ob- 
stetrical operations). — Monatschrift f. Geburtsk. April and May. 

3. Rousseau-Pommeret, G., on the Obstetrical Operations in Cases of 
Considerable Contraction of the Pelvis. Thesis. Paris : Rignoux. 
In 4. 

4. Mayer, L., Jun., the Indications for Induction of Abortion. — Monat- 
schrift f. Geburtsk. Feb. 

5. Induced Abortion, on Account of Extreme Narrowness of the Pelvis. 
Prize Essay of the Med. Faculty of Tubingen. Abridged and Pub- 
lished by F. Rattenmann, M.D., formerly Assistant Physician at 
the Lying-in Hospital at Tubingen. Philadelphia: R. Stein. 8vo. 
pp. 51. 

6. Lee, R., on Induction of Labor before the Seventh Month of Preg- 
nancy. — Med. Tim. and Gaz. May, 8. 

t. Kirby, E. A., Induction of Premature Labor in a Dwarf. — Lancet 
II. 2. July. 

8. Bullen, H. St., Induction of Premature Labor in Deformity of the 
Pelvis.— -Lancet. May. 

9. Hausmann, Case of Induction of Premature Labor after Cohen's 
Method. — Monatschrift f. Geburtsk. May. 

10. Coesfeld, Two Cases of Induction of Premature Labor after Cohen's 
Method. — Med. Vereinszeitung, No. 9. 



292 

11. Credd, Three Gases of Induction of Premature Labor after Cohen's 
Method. — Monatschrift f. Geburtsk. February. 

12. Riedel, Six Cases of Induction of Premature Labor after Cohen's 
Method. — Monatscbrift f. Geburtsk. January. 

13. Birnbaum, My Experience with Regard to Intra- Uterine Injections 
for Inducing Premature Labor. — Deutsche Klinik. 34. 

14. German, on Induction of Premature Labor. — Monatshcrift f. Ge- 
burtsk. Oct. Dec, etc. (Not complete.) 

15. Lumpe, Four Cases of Induction of Premature Labor. — "Wien. 
Wochenschrift. No. 1. 

16. .Stoltz, on Induction of Premature Labor. — Gaz. do Strasbourg. 8. 
11. Braun, C, on Induction of Premature Confinement by Means of 

Gut-Strings Introduced into the Uterus. — Wien. Wochenschrift. 
Nov. 13. 

18. Gardner, A. K., an Obstetric History of one Woman. — Maine Re- 
port. I. 1. Dec. 

19. Smith, Andr., Cephalic Version in Arm Presentation. — Lancet. II. 
5. Nov. 

20. Figg, E. G., on Delivery of the Child by Turning as a General 
Rule in Labor. — Med. Tim. and Gaz. 431. Nov. 13. 

21. Barker, Fordyce B., on the Comparative Use of Ergot and Forceps 
in LaboT*.—^ Americ. Monthly. X. 1 . July. 

22. Barker, F. B., on Forceps and Turning (Proceedings of the Ob- 
stetric Section of the New York Academy of Medicine.) — Ibid. X. 
4. Oct. 

23. Spiegelberg, 0., Remarks on Forceps and Turning in Arm Pre- 
sentation. — Monatschrift f. Geburtsk. May. 

24. Elliot, G. T., Description of a neio Midwifery Forceps, having a 
Sliding Pivot to Prevent Compression of the Foetal Head. (With 
Cases). — New York Jour. V. 2. Sept. 

25. Gross, Dilatation of the Vagina by the knife; Forceps Operation. — 
Wiirtemberg. Corr.-Bl. 31. 

26. Lee, R., History of a Forceps Case. — Med. Tim. and Gaz. 429. 
Sept. 18. 

21. Schultze, B., Indications for Kephalotripsis. — Med. Centr.-Ztg. 50, 
51.— Med.-Chir. Mon.-Hefte. Sept. 

28. Krieger, Case of Keptalotripsis. — Med. Centr.-Ztg. 38. 

29. Richard, Th., Kephalotripsis by the Hand with the Aid of Perfora- 
tor and Crotchet. — Monatschrift f. Geburtsk. May. 

30. North, N. L., of Brooklyn, N. Y., Difficult Labor; {Hydrocephalic) 
Monster; Craniotomy without Instruments. — Buffalo Jour. III. 14. 
August. 

31. Lee, R., History of a Case of Craniotomy. — Med. Tim. and Gaz. 
431. Oct. 2. 

32. Ben Ezri, of Columbia, S. C, Gleanings from the History of the 
Caesarian Operation. — Oglethorpe Jour. I. 4. Oct. 



293 

33. Pagenstecher, C, Four Deliveries in Cases of far Advanced Con- 
traction of the Pelvis. — Monatschrift f. Geburtsk. XII. 1. Aug. 

34. Frericks, T. S., and Groesbeck, J. A., on Some Cases of Caesarian 
Operation luith Happy Result for Mother and Child. — Nederl. 
Tijdschr. II. Jan. 

35. Duclos, Ccesarian Operation with Happy Result for Mother and 
Child. — Rev. Med. — Gaz. des Hop. 35. 

36. Alonso, F., Ccesarian Operation in a Case of Intra-Uterine Preg- 
nancy of 22 Months' Duration, with Happy Result. — El Siglo Med. 
July. 

37. Hawkins, J., Ccesarian Section with Happy Result for Mother and 
Child. — Med. Tim. and Gaz. May, 8. . • 

38. Mertens of Neviges, Two Ccesarian Operations with Happy Result 
for the Mother.— Org. f. d. ges. Heilk. VI. 1. p. 31. 

39. Chevillon, Gastrotomy and Recovery in a Case of Extra-Uterine 
Pregnancy of Six Years' Duration. — L'Union de la Gironde. Feb. 

40. Dombre, on Ccesarian Section. — Gaz. des Hop. 69. 

41. Greenhalgh, Ccesarian Section for Extensive Disease of the Bones. 
— Med. Tim. and Gaz. May, 1. 

42. Pischen, on Ccesarian Section. — Rev. Med. March, 31. 

43. Owens, F. R., Ccesarian Section Performed after Death of the 
Mother. — Recovery of the Child. — N. Carol. Jour. I. 1. August. 

44. Mordret, on Death after Ccesarian Operation. — Rev. M6d. May, 15. 

Dr. Meissner's report relates to 3,811 women, whj> gave birth to 
3,980 children, as 136 were twins, and 2 triplet births. These 3,811 
labors called for operative interference in 3,025 instances, dynamic 
aid being required in 924 of these to effect a change of position. Out of 
351 cases of turning, only 222 did prove completely successful for both 
mother and child. In 104 cases the child was born dead ; in 2 cases 
the mother died from delivery, and in 2 after this had taken place. 
Dr. Meissner prefers turning by one foot, as all German obstetricians 
do, unless there is some indication for hastening the delivery. This 
rule is of especial importance when multiple birth is expected, so 
as to avoid getting hold of two feet of separate children. In one of 
the author's cases of triplets, all the children presented crosswise, 
and six lower extremities were felt. All the children were safely de- 
livered by operating upon one foot at a time. Cephalic version is 
preferred by some practitioners, as giving the child the best chance; 
but it can only be tried when hastening the delivery is not an 
object. The author resorted to it in 6 cases. In 4 of the 351 cases, 
turning was performed by external manipulation, and in 3 by spon- 
taneous version, the buttocks being forced by the presenting 
shoulder into the pelvis, and all the children being born dead. Of 
1,853 cases of forceps operation, in 1,750 the head was the present- 
ing part, and in 113 the forceps were used for its delivery in other 
presentations. Of the 1,^54 children 99 were born dead, but many 
of these children had died during pregnancy, and were in advanced 
purification on delivery. In 10 instances the child was hydro- 



294 

cephalic ; in 3 the mother was already dead ; there were 5 cases of 
spina bifida ; 1 deaths took place from prolapsed funis, and 3 from 
the arm'and head being tightly wedged in together. In 4 instances 
the mother had suffered from repeated convulsive paroxysms. In 
other cases the application of the forceps had been repeatedly 
attempted by preceding practitioners, or the passage was narrowed 
by the presence of tumors. Extraction was performed in 241 cases, 
and became necessary when in breech, knee, or foot presentation, 
the child's life was threatened by cessation of pain, faulty position, 
or prolapsus of funis. Only 145 of the children were born living ; 

13 had died through pressure on the funis, before the author's 
arrival ; 18 were in a state of putrifaction ; 10 were already born 
except the head ; 8 were immature, and in 5 others there was hydro- 
cephalus, or other forms of dropsy. In 42 instances extraction had 
to be performed on account of cessation of pain after turning. Per- 
foration has been performed by the author 32 times, and he has 
always followed the maxim, of never proceeding to the operation 
until assured of the child's death ; and it has several times happened 
to him to see living children born in cases which have been left for 
days together to the powers of nature, and which in previous labors 
had been delivered by perforation. Premature labor was induced 20 
times, and never before the 36th week. Accouchement force was 
performed 55 times. By this term the author understands the whole 
series of operations (as artificial dilatation of the os uteri, bursting 
the membranes, turning, extraction, or removal of the placenta) 
which may be required for delivery when the further continuance of 
pregnancy is datigerous to mother and child. It is especially called 
for in cei'tain cases of eclampsia, placenta praevia, and obstinate 
vomiting. Two instances are enumerated of opening the adherent 
os by the knife, and eight cases of its forcible dilatation. In thirty- 
three of these cases both mother and children did well, although, as 
the dilatation was usually undertaken for placenta praevia, most of 
the latter were born some weeks too soon. As the majority of cases 
(31) were examples of placenta praevia, in which hemorrhage had 
continued long before the patients were seen by the author, it is not 
surprising that ten of the mothers died. Of the 6 Caesarian opera- 
tions, 5 were performed on mothers being already dead, the children 
being saved in none. In the case of operation upon the living sub- 
ject, both mother and child lived. The general results were as fol- 
lows : Of the mothers, 41 were lost — 25 during and 16 after de- 
livery. Of the former 25, 11 were already lifeless when seen ; of the 

14 others, 1 died from rupture of the omentum with internal haemor- 
rhage, 10 from placenta praevia, necessitating forced delivery, 2 from 
nervous shock after favorable labor, and 1 from hemorrhage. Of the 
16 mothers who died after delivery, 1 died from cancer of the 
stomach, 1 from pneumonia, 3 after repeated attacks of eclampsia, 1 
from putrescence of the uterus, 1 from typhus, 4 from puerperal 
fever following operative procedures, 1 from paralysis of the lungs, 
3 from the consequences of loss of blood, and 1 after several hours' 
operative attempts by a country practitioner. Of the children, 399 
were born dead, as already stated, under the various operations. 



295 

Besides these, 36 died within fourteen days after birth — 4 from 
debility, from too early birth, 6 from atelectasis pulmonum, 2 from 
trismus, 1 from fissure of the cranium after a forceps operation, 1 
from chronic hydrocephalus, and 2 from want of breast-milk. The 
author remarks that, as a general rule, forceps operations are found 
to be most frequent in cold, changeable weather, which induces 
rheumatic affections of the uterus, not only rendering dilatation of 
the os very painful, but delaying its accomplishment for days. 
When adhesion has taken place repeatedly at the same place, in con- 
sequence of an indurated condition of a portion of the uterine wall, 
we should, after the termination of the puerperal condition, endeavor 
to induce absorption by mercurial or iodine medicines, or by the use 
of alkaline mineral waters. 

Every reader will be surprised at the great number of operations 
performed and the large amount of fatal cases. But this is readily 
accounted for by the fact, that scrofulous and rhachitic diseases are 
unusually common among the inhabitants of Saxony, by the fact, 
that Dr. Meissner, the obstetric veteran, is the very man who is 
called in consultation whenever a case has come to the worst ; by 
the fact, that German practitioners in general have to attend more 
often to pathological than normal confinements — the latter being 
left to the care of our well-trained and trustworthy midwifes, who 
are forced by State law to call in a physician as soon as a confine- 
ment shows the slightest deviation from the natural course. 

Dr. L. Mayer, in a paper read before the Berlin Obstetrical 
Society, on induction <5f abortion, considers this operation justifiable 
under the following conditions — 1. Extreme contraction of the pelvis. 

2. Very narrow constriction of the vagina. Some of the members of 
the Society remarked, that a vagina, contracted even to the utmost 
degree, was very often softened and easily dilatable during labor. 

3. Large tumors of the rectum and of the vagina. 4. Retroversion 
of the pregnant uterus, if the reduction cannot be effected. 

Dr. Rattenmann has very properly, we think, deemed it important 
to reproduce his thesis on artificial induction of abortion, in an 
English version. The little book is intended to discuss the question, 
whether induced abortion in case of extreme narrowness of the pel- 
vis, is to be received as one of the legitimate obstetrical operations. 
In order to prove under what circumstances induced abortion is 
a justifiable operation in a medical point of view, Dr. R. first consid- 
ers the extreme limits of the dimensions of the pelvis, which will not 
even admit of the escaping of an immature foetus, and in which the 
operation in question is the only means left, to save the mother from 
almost certain death, viz.: Caesarian operation ; he then proceeds to 
give an account of the dangers connected with Caesarian section 
and of the statistics of its fatality ; nor does he omit to glance at 
the proposed craniotomy of the child, and to consider the dangers to 
which the mother is exposed in the different attempts of saving the 
child. The knowledge of the exact degree of pelvic contraction is of 
course not a sufficient guide to decide whether the child may be de- 
livered by craniotomy with safety to the mother, or whether the ex- 
treme means, as the Caesarian operation, or induction of abortion, 
are called for ; the final settlement of this question depends too much 



296 

upon the size of the foetus. Although craniotomy has been performed 
with perfect success to the mother, in pelves with antero-posterior 
contraction up to li" and 1" (Osborn, Wigand, Michaelis), a pelvis 
of less than 2£" diameter, will, as a general rule, not allow even a 
dead and perforated foetus to pass, without fatally injuring the 
mother. In these cases the question arises, shall we put the mother 
to all the hazards of a Caesarian operation, or ought we to sacrifice 
one life in order to save another. A perusal of the statistical records 
with regard to Caesarian section, from 1750 to 1854, shows the fol- 
lowing results : Of 801, upon whom this operation was performed, 
501 died, and 294 were saved ; while not a single woman escaped 
of those who underwent this operation in one of the large hospitals 
of London, Paris or Vienna. The statistics of mortality would be 
greatly increased if all those cases could be taken into account which 
have not been published, as the greater number of Caesarian opera- 
tions which are kept secret, have resulted fatally (Naegele, Ionouli, 
Wilde). It further appears from the results recorded in literature, 
that perforation and kephalotripsis are operations which endanger 
the life of the mother to a considerable extent, and therefore the only 
way to safely deliver a woman with a pelvis, which makes all obstetric 
operations impossible, with the exception of the Caesarian section, is 
the induction of abortion. When speaking of the comparative value 
of craniotomy and Cassarian section, and mentioning that with a di- 
ameter of 2|" craniotomy is more dangerous than the Caesarian 
operation, Dr. Rattenmann says : "To get easily and pleasantly out 
of this difficulty, we have only to follow the advice of Kilian (Vol. II. 
p. 280), which is to desert the mother, meaning to let both mother 
and child perish without interfering. The words of Kilian are : 
'When the accoucheur has exhausted all allowable means of persua- 
sion, it is his duty to leave the mother, who refuses to submit to the 
Caesarian section, without doing anything further.'" — In this state- 
ment the meaning and words of Prof. Kilian are misrepresented. 
The exact English version of Kilian's words runs as follows : " It is 
the duty (of every accoucheur) to leave this woman (who refuses to 
have Caesarian section performed) when he has exhausted all means 
of persuasion, and to leave her to her own mercy, until she has come 
to another conclusion, prompted perhaps by the advice of her minister, 
etc., or until the final death of the child imperatively demands perfora- 
tion and extraction? (See : Die Operative Geburtshiilfe, Vol. II., p. 
737. Ed: 1849.) The meaning of these words differs much from 
that given by Dr. Rattenmann, and it does not deserve derision. 
Kilian does not leave the woman " without doing anything further," 
but he leaves her to consult with her relatives and friends before de- 
livering herself up to an operation, which, with laymen, is synonymous 
with death. Thus he resorts to every means to avoid craniotomy, 
which in those cases where the pelvis is contracted to such a degree 
that Caesarian section is thought of, must be considered the most dis- 
gusting and most dangerous operation in midwifery. — E. N. 

The chief indication for inducing abortion is the refusal of the 
mother to allow the Caesarian operation to be performed in case she 
should go to the full term. 

Dr. Rattenmann asks : " Why should we hesitate to destroy the 



297 

child, where our object must be to preserve the life of the mother, 
and why should we not respect her just claims ?" From the cases 
reported where abortion had been induced for diseases threatening 
the life of the mother, it appears that this operation was performed 
with perfect safety to the mother. When the shortest diameter of 
the pelvis is less than 2 or 2£", abortion is indicated, and is justi- 
fiable, when the pregnancy has not yet reached the seventh month. 
As a guide in practice, two tables are inserted upon page 33, repre- 
senting the transverse diameter of the fcetal heads at different stages 
of development from the 10th to the 40th week. Rejecting the ob- 
jections raised to the operation, Dr. Rattenmann proceeds to discuss 
the different methods of inducing labor (rupturing the membranes ; 
dilatation by sponge-teajts ; plugging of the vagina ; injections into 
the vagina or uterus ; galvanism ; medicines). After having 
enumerated the medical reasons for inducing abortion, the author 
considers the operation from a theological point of view. The fifth 
commandment says: "neoccidas;" but taking into consideration 
the dangers incident to the Caesarian section, the same injunction 
applies to the latter operation, and as the performance of hysteroto- 
my is not considered a sin, no objection can be made to induction of 
abortion. In discussing the legal bearings of the question, Dr. Rat- 
tenmann strictly adheres to the rules laid down by Naegele, which 
are based upon the right of self-preservation. In applying the laws 
of self-defense to the induction of abortion, the author argues in this 
way : " In a case where abortion is positively indicated, two not 
equal rights are opposed to one another, but a weaker right comes in 
contact with a stronger. The life of the mother, namely, appears 
a real life, that of the foetus only a possible one. For as the foetus 
has not yet obtained that conformation and development to enable it 
to sustain life independently, we can only look upon it as a possible 
life, which in law, cannot, by any means, be considered of equal 
value with the real life of the mother." And further the author says : 
"The mother at the period when abortion may still be induced suc- 
cessfully, is actually under duress, on account of the great fatality of 
the Caesarian section. We must therefore, if the natural develop- 
ment of the foetus proceeds uninteruptedly, look upon the mother as 
threatened by certain death ; and as the mother is possessed of the 
natural right of self-preservation, of which she can only avail herself 
at the expense of the life of the foetus, we must consider the mother 
as under duress, and allow her the exercise of the right of self-preser- 
vation, to the fullest extent, in the induction of abortion. The cir- 
cumstance that the physician is not himself under duress can be no 
motive to exclude his active assistance ; for he is only the means 
and the tool of which the mother makes use to realize her right ; the 
mother is the actually acting person ; she causes the abortion, the 
physician, properly speaking, is only the medium, by which the 
mother strives to preserve her own life, and thus exercises her right." 
Therefore, Dr. Rattenmann, thinks himself justified in recommend- 
ing induction of abortion : (a) Whenever the mother refuses to sub- 
mit to the Caesarian section ; (b) when embryotomy is not practicable, 
with a narrowness of the pelvis of less than 2^" 



298 

Dr. Lee reports a case where labor was induced before the fifth 
month of pregnancy in a woman with osteomalacia of the pelvic 
bones, in order to avoid Caesarian operation. 

Dr. Cohen's method of inducing premature confinement, seems to 
become the favored method among German obstetricians, it has been 
performed this year almost exclusively of every other method 
hitherto in use for the same purpose. 

Dr. Hausmann published a successful execution of Cohen's method. 
A few hours after the first injection labor pains set in ; twenty-four 
hours afterwards the orifice was fully dilated ; two injections were 
made, and sixty-three hours after the first injection the membranes 
ruptured, and soon a living child was born. 

Dr. Crede reports three cases in which he lately induced prema- 
ture confinement for contraction of the pelvis, by injecting warm 
water into the uterus. In all the cases, only one injection of from 
eight to ten ounces of lukewarm water was required. The time from 
the first injection up to the expulsion of the child, was respectively 
sixteen, seventeen and one-half, and twenty-three hours. Two chil- 
dren were born alive ; one was dead in consequence of prolapse of 
the umbilical cord. The women scarcely had any sensation of un- 
easiness when the water was injected. 

Dr. Riedel gives an account of his six cases of induction of prema- 
ture labor, by intra-uterine injections. The fact, that four of these 
children were stillborn, is accounted for by their malposition and 
consequent turning, thus exculpating the method from any blame. 
The time of labor from the first injection was respectively five, six, 
eleven, forty, forty-four, and sixty-three and one-half hours. This 
makes an average time of twenty-eight and one-half hours. The 
author insists upon the necessity of retaining the injected water for 
some length of time in the uterus. 

Dr. Birnhaitm used this same method in seven instances, partially 
combined with other methods, partially alone. Not one operation 
was followed by evil consequences. Of seven children, five were 
born alive ; of which number, one died soon afterwards, two died 
during the operation of turning and extraction. No death occurred 
which might have been attributed to the method. The time between 
the injection and the beginning of the first labor pains was respective- 
ly one half hour, two, five, seventeen, seventy-two hours, and the time 
of actual labor respectively, one, three, six, ten, six, ten hours. 
Therefore, the effect of this method is sure and prompt, and demands 
only in very rare instances a combination. 

Dr. Stoltz reports the case of a woman who was prematurely 
delivered by injections of warm water into the vagina, with a com- 
mon enema-syringe. After the eighth injection, labor was fairly es- 
tablished. Dr. Stoltz seems to prefer this method to others. 

Dr. Braun, in considering the different methods for inducing prem- 
ature confinement, proposes a new one, or rather a modification of 
Krause's method. Instead of an elastic catheter, Dr. Braun makes 
use of a gut-string, which he introduces into the cavity of the womb, 
between the walls of the uterus and the chorion, to remain there 
until expelled by the advancing labor. The principal reason why 



299 

i 

Dr. Braun prefers a string, is the fact that the membranes had been 
ruptured in some instances, especially when the stiff English catheter, 
with inflexible mandrin, had been used for the purpose. This accident 
happened at the moment, when the mandrin was withdrawn, while it 
was not observed when an elastic, French catheter was applied with 
flexible mandrin. In order to make the use of strings even safer, Dr. 
Braun proposes to have the point of the strings dipped into hot 
water to the length of about half an inch, by which process they be- 
come very pliable and inoffensive. Dr. Braun resorted to this 
method of intra-uterine catheterism in twelve instances. The re- 
sults were as follows : eleven children were born alive ; five still- 
born ; eight mothers recovered entirely ; four died from diseases 
unconnected with the puerperal state (one pneumonia, one tuber- 
culosis, two Bright's disease). Gut-strings were used five times, 
flexible French catheters four times, and in no instance the mem- 
branes were ruptured ; the English catheters, having a very small 
amount of elasticity, were used three times, and in every single in- 
stance, the membranes were ruptured. The shortest time of labor 
after the introduction of a gut-string was five hours, the longest term 
one day. Added, is the history of the above-named twelve opera- 
tions. As a a sample, we will reproduce 

Case VI. Fistula vesico-vaginalis and pregnancy ; induction of 
premature labor, by means of a gut-string for contraction of pelvis ; 
recovery of the mother. 

Johanna H., thirty years of age, was delivered thirteen years ago 
of a premature dead child. At the full term of her second pregnancy, 
craniotomy was performed on her for contracted pelvis of 3-3 \" 
antero-posterior diameter, as the forceps had failed to deliver her ; a 
vesico-vaginal fistula was established after this operation. The fis- 
tular opening had been reduced to a very limited extent by suture, 
when the patient became pregnant for the third time. Her last 
menstrual courses appeared towards the end of October, 1851, and 
the first quickening was remarked in February, 1858. 

On May It, 1858, premature labor was induced by introducing a 
gut-string 10" long and 2"' thick, between the uterine wall and the 
chorion, as high up as 8", to remain there. Two hours afterwards 
labor pains set in, which twenty-two hours later expelled the string, 
and effected the birth of a stillborn child (of 4 pounds weight and 
IV length), in a cranial presentation. The mother recovered 
promptly. 

In case V. it was impossible to push a gut-string through the os 
uteri, " as it was narrowed by cicatrices," and the membranes were 
ruptured on purpose by an English catheter. 

Dr. Gardner reports the history of a woman who had been de- 
livered three times by craniotomy for contracted pelvis. In the 
seventh month of her fourth pregnancy, premature labor was induced 
by the douche inserted into the mouth of the uterus. 

Dr. Andrew Smith reports a case where cephalic version was suc- 
cessfully resorted to in an arm presentation. Dr. Smith prefers it to 
turning by the feet, on account of the large amount of infantile mor- 



300 



tality in footling cases. He recommends it for all cases in which the 
safety of the mother does not call for speedy delivery. 

By a comparison of the respective advantages and disadvantages 
of the operations of turning and forceps, in cases of protracted labor, 
where the head is floating above the brim, Dr. Figg advocates Simp- 
son's method of turning, instead of delivery with the forceps. In a 
P. S., the author says : — "Since writing the above observations some 
months ago, I have attended sixty labors, three of which alone have 
been conducted as head presentations. Of the remainder, two were 
breach presentations, and the other fifty-five were conducted accord- 
ing to the principles advocated in the above communication, viz.: 
the children were all delivered by turning." It seems that our Lord 
made a mistake when he ordered the children to be born calvaria 
prsevia, and Dr. Figg is called to correct this error. — E. N. 

The article of Dr. Barker on the comparative use of ergot and for- 
ceps is, as all his articles are, replete with literary and practical 
knowledge, and written with a great deal of sound judgment. He 
confines the use of ergot only to very few cases, viz., to cases of 
inertia uteri, in the last stage of labor, at a time when delivery is 
expected to be finished before an hour. In the first stage of labor it 
ought to be applied only in cases of partial presentation of the 
placenta, for the purpose of controlling the hemorrhage. W^ith regard 
to post-partum hemorrhage, the author recommends this drug for 
those cases which occur in plethoric women, with flushed skin, thirst, 
and bounding pulse, while in those cases where the countenance is 
sunk, the lips blanched, the skin cold, the pulse gone, the opium will 
act like magic. As a remedy for retention of urine after labor, ergot 
in doses of twenty drops of the tincture, repeated every half hour, 
is of greatest importance. After stating the different indications for 
the application of forceps, Dr. Barker says : — "In conclusion, I must 
state my conviction, that the more enlarged is the clinical experience, 
and the more accurate the observation, the more rarely will the ergot 
be used before delivery ; and furthermore, that the fear of delay in 
labor will be greater than the apprehension from the use of forceps." 

Dr. Barker gives the history of a case, where turning was substi- 
tuted for the application of the long forceps, in order to save the life 
of the child. The danger consisted in the cord being wound three 
times around the childs neck, pulsating very feebly. If the cord 
should happen to be very short, not only would the life of the child 
be imminently jeopardized, but that of the mother, also, from forci- 
ble detachment of the placenta. The child was still-born, but resusci- 
tated. 

Dr. Elliot describes a new forceps with a pivot, which can be 
moved upwards and downwards, thus keeping the blades at a dis- 
tance from another, so as to avoid undue pressure upon the foetal 
head. This sliding pivot is a happy modification of Mende's appara- 
tus. — E. N. The usefulness of the instrument is illustrated by a 
large number of cases. In order to render the forceps applicable in 
a great variety of cases, especially when the head is floating above 
the pelvic brim, and when even the os is undilated, the instrument is 
slender and long, with only a slight pelvic curve. It is 15£ inches 



301 

long ; extreme width between blades 2\% inches ; length of blades 
6f inches ; the width of the fenestra only |3 f an inch. The blades 
are very thin, the handles long and powerful. 

Dr. Lee records a case, where it could not be ascertained whether 
the child was alive or dead, and he therefore proposes to inquire into 
the comparative temperature of dead and living children, in order to 
ascertain whether this way might not become of usefulness for diag- 
nosis. 

Dr. Schultze remarks, that the limits of a justifiable operation with 
the craniotomy-forceps, for removing a full-grown child, are 2^" or 
2" antero-post. diameter of the brim. Below two inches the extrac- 
tion of a full-grown child never ought to be attempted. The non- 
attendance to this rule has destroyed many mothers. Dr. Schultze 
cautions against the proposition of turning the child, in cases of con- 
siderable obstruction, to avoid craniotomy, because after the opera- 
tion of turning has been performed, it is often necessary to apply the 
perforator to the head remaining in the uterus, beneath the shoulders — 
a feat very difficult to perform. We heartily subscribe the author's 
veto from our own experience ; we have been led to act once on this 
principle, for the first and last time, proclaiming, with Dr. Dubois, 
" On ne m' y prendra plus 1 " — E. N. It is equally wrong to deliver 
a full-grown child through a pelvis of less than 2|" shortest diameter. 
Between 2|" and 2" shortest diameter, it is impossible to produce a 
living child on the natural way — the Caesarian operation alone gives 
a chance of saving mother and child. But the life of the child has to 
be sacrificed, as soon as its integrity has become dubious, by 
previous attempts to operations or other circumstances. By Caesarian 
operation we are justified to endanger the life of the mother for 
saving the life of the child ; but to put a mother's life at stake for a 
child of questionable vitality, is an act of inhumanity. But in pelvic 
contractions of 2|" shortest diameter and upwards, the rules to be 
followed are different. Here it is where to the forceps ought to be 
given a full and fair trial, and the perforator must be kept behind, 
until the former way is abandoned as insufficient. If, however, the 
child is notoriously dead, we must abstain entirely from the use of 
the forceps, considering that an easy kephalotripsis gives a better 
chance to the mother than a difficult forceps operation. 

Dr. Lee reports another case, where he perforated and extracted 
the head of a child, which rested upon the perineum. In concluding 
the article he says : It might now I think be considered as an 
aphorism in midwifery, that the forceps is not applicable to dead 
children, nor in cases where the os uteri is not fully dilated, and the 
head has not descended into the cavity of the pelvis and can be felt. 
— The writer ventures to express his humble opinion, that a dead 
child, with its head resting upon the perineum, is quicker delivered 
by forceps than by the craniotome, and with the same safety and 
comfort for the mother. 

Dr. Ben Ezri's article on the history of Caesarian operation, is in- 
tended to prove, from the Jewish Talmud, that this operation had 
been in use as far back as 130 ante-christum. [This same opinion 
has been advanced by Dr. Mannsfeld in his thesis : Ueber das Alter 



302 

des Bauch- und Gebarmutterschnitts an Lebenden. Braunschweig, 
1824. 8.— E. N.] The words alluded to by Dr. Ben Ezri may be 
found in the Mishna, Section VII. : " The male child born by an ope- 
ration on the side of the mother, and one bora after it (twins), 
neither of them is considered a first-born, in regard to inheritance or 
to the redemption by the priest ;" and further, in Tractat. Nidda, 
Sec. V. : "A child born by means of an operation performed on the 
side of the mother, the law does not compel the mother to observe 
the prescribed days of impurity and purity." From these quotations 
the author concludes that no better proof was necessary than the 
certainty with which the above passages express, not only a knowl- 
edge of the Sectio Caesarea, but also that the operation was perform- 
ed on living beings, and that their lives were preserved. 

We have received this year an unusually large number of success- 
ful Caesarian operations — 2 by Dr. Pagenstecheb, 2 by Frericks and 
Grcesbeck, 1 by Duclos, 1 by Alonso, 1 by Hawkins, 2 by Mertens, 
and 1 by CheviUon — the latter in a case of extra-uterine pregnancy. 
The cases reported by Dr. Mertens go to show, what many obstetri- 
cians can confirm by their own experience, that often the apparently 
most unfavorable cases result in general satisfaction. 

Case 1. — A primipara, 30 years of age, perceived the first labor 
pains on November 25, 1856 ; but during the progress of labor the 
head became so firmly incarcerated in the pelvis, that the enormous 
caput succedaneum prevented a closer examination of the pelvic 
diameters. It was impossible to apply the forceps, and when the 
child was ascertained to be dead, his head was perforated and dimin- 
ished, after which the accoucheur was able to perceive that Caesarian 
section was even now the only means left for delivering the woman. 
This was performed in the linea alba. The patient recovered finally, 
notwithstanding her taking cold three days after the operation, in 
consequence of which an obstinate cough, with swelling and tender- 
ness of the abdomen , set in. She left her bed after four weeks . 

Case 2. — A multipara, who had been delivered two years previous- 
ly by the Caesarian operation, was taken sick on January 6, 1856. 
The uterus was now situated in a sac formed by the abdominal wall, 
and extended downwards to the middle of the thigh ; the cut ran 
alongside the linea alba. The womb being very thin, the incision 
touched the placenta, which was removed immediately with the 
living child. The patient left her bed ten days after the operation, 
in consequence of which she caught cold and was taken with inflam- 
mation of the left ovary, after which an abscess formed and broke in 
the vaginal region. The patient also recovered from this accident in 
three weeks. 



303 



REPORT 



PROGRESS OF INFANTILE PATHOLOGY IN 1858. 



I. MANUALS, GENERAL PATHOLOGY, DIETETICS, 
STATISTICS, ETC. 

1. Hennig, K., Lehrbuch der Krankheiien des Kindes in seinen ver- 
schiedenen Altersstufen. Zweite Auflage. Leipzig, 1858. pp. 476. 
{Manual of the Diseases of Children in Different Ages.) 

2. Condie, F., a Practical Treatise on the Diseases of Children. Fifth 
Edition. Philadelphia, 1858. pp. 162. 

3. Meigs, J. F., M.D., a Practical Treatise on the Diseases of Children. 
Third Edition. Philadelphia, 1858. pp.724. 

4. Tanner, T. H., a Practical Treatise on the Diseases of Infancy and 
Childhood. London, 1858. pp. 408. 

5. Mayr, Fr., Politzer, L. M., Schuller, M., Jahrbuch fur Kinderheil- 
kunde und Physische Erziehung. 1857,1858. I. 1 — 4. II. 1 — 2. 
(Annual for Infantile Pathology and Physical Education. Six num- 
bers.) 

6. Behrend, Fr. J., und Hildebrand, A.-, Journal fur KinderkrankheUen. 
1858. 1 — 12. (Journal for Diseases of Children. Six bimonthly 

•numbers.) 

7. Mayr, Fr., on Examination and Semiotics of Sick Children. — Jahr- 
buch f. Kind. II. 1. 

8. Cumming, W. H., on a Substitute for Human Milk. — Am. Monthly. 
March. 

9. Cumming, Wm. H., on Natural and Artificial Lactation. — Am. 
Jour. July. 

10. Politzer, L. M., on Scientific Dietetics and Physical Education of 
Children. — Jahrb. f. Kind. 3, 4. 

11 Routh, C. H. F., on Vegetable Substitutes for Human Milk.— Med. 
Tim. and Gaz. Aug. 21, 28. 

12. Routh, C. H. F., on the Mortality of Infants in Foundling Hospitals, 
and Generally as Influenced by the Absence of Breast-Milk. — Brit. 
Med. Jour. Feb. 6, 13, 20. 

13. Aravaca y Forrest, Practical Considerations on Lying-in Women 
and Newborn Infants. — II Siglo Med. 228. 



304 

14. Caron, A., Hygiene for Newborn Infants, Considered in Relation to 
their Phxjsical and Moral Development. — Gaz. des Hop. 142. 144. 

15. Chabrely, B., on Hygiene of Infants in their Earliest Age. — Jour, de 
Bord. Nov. ■ 

16. Patron, August, De Vallaitement maternel. Paris. These, pp. 34. 
(On Maternal Lactation.) 

It. Besser, Leopold, DenDeutschen Muttern und Vaternein Buch uber 
das Werden und Wachsen ihrer Kinder als Schlussel zu deren Gesun- 
derer Erziehung. Frankfurt a. M., 1858. pp.344. (A Book for 
German Mothers and Fathers, on the Formation and Growth of 
Children, being a Key to their Sound Education.) 

18. Gauneau, J '., Education Physique et Morale des Nouveau-Ne's, Suivi 
de V Importance deVAllaitement pour la Mere. Paris, 1858. pp.106. 
(On Physical and Moral Education of Newborn Children, with an 
Appendix on the Importance of Nursing to the Mother.) 

19. Hufeland, Chr. W., Guter Rath an Mutter uber die Wichtigsten 
Punkte der Physischen Erziehung der Kinder in den Ersten Jahren. 
Nebst einem Unterrichte fur Junge Eheleute, die Vorsorge fur Unge- 
borne betreffend. Leipzig, 1858. pp. 257. (Advice to Mothers on 
the most Important Points in the Physical Education of Children in 
the First Years of Life. With instructions to young couples on the 
care of the Unborn.) 

20. Plath, Wilhelm, Brief "e ernes Arztes an eine Junge Mutter. Ham- 
burg, 1858. pp. 308. (Letters of a Physician to a Young Mother.) 

21. Declat, G., Hygiene des Enfants Nouveau-Ne's. Paris, 1858-1859. 
pp. 316. {Hygiene of new-born children.) 

22. Schreber, D. G. M., Kallipaedie, oder Erziehung zur Schbnheit, etc., 
Mit 12 Abbildungen. Leipzig, 1858. pp. 309. (Kallipaedia, or 
Development of Human Beauty by Education, etc.) 

23. Sehbpf-Merei, A., and Whitehead, J., Second Report on the Hos- 
pital for Diseases of Children at Manchester. — Jour. f. Kinderkr. 
9, 10. 

24. The Murder of the Innocents. — Lancet. May. 

25. London Hospital, Returns of Patients under Seven Years of Age 
in the Children's Ward during the Year 1857. — Lancet. April. 

26. Helfft, on the Mortality during the First Year of Life, of Children 
Born Alive at Berlin. — Monatsbl. f. med. Statistik. 2. 

27. Raedell, C, Contributions to the Statistics of Newborn Children 
at Berlin. — Ibid. 9. 

28. Husemann, Th., Contributions to the Medical Statistics of the Prin- 
cipality of Lippe. — Ibid. 1. 

29. Scherzer, C, Medical Notes. — Wiener Zeitschrift. 45. 

30. Moore, W., Contributions to Infantile Pathology. — Dubl. Hosp. 
Gaz. Aug. 15 — Journal f. Kinderkr. 

31. Stendel, H. and Gartner, 0., Second Report on the Jatrogymnastic 
Institution at Stuttgart. — Journal f. Kinderkr. 1, 2. 



305 

32. Hauner, Report on the Eleventh Year of the Dispensary Connected 
with the Children's Hospital at Munich*—\h\(\. 7, 8. 

33. Faye, F. C, The Children's Hospital at Christiania in the years 
1855-1857.— Ibid. 7, 8. 

34. Ldscher, Jahresberichi des Franz Joseph Kinderspitals in Prag, 
vom Jahre 1857. (Annual Report on the Francis Joseph Children's 
Hospital of Prague, for the year 1857.) 

35. The Hospital for Sick Children. — Brit. Rev. Jan. 

36. Reports of Continental Children's Hospitals. — Edin. Med. Jour. 
March. 

37. Herrnhilfe zu Wildbad, Filial der Kinderheilanstalt zu Ludwigs- 
burg, zur Verpjlegung Badebed'drftiger Kinder; der 4. Sommer da- 
selbst. Ludwigsburg. pp. 20, ( Herrenhilfe at Wildbad, Branch of 
the Children's Hospital at Ludwigsburg; for the Purpose of Talcing 
Care of Children Needing Baths; the Uh Summer.) 

38. Dissauer, The Children's Hospital at Qraz. — Jahrb. f. Kind. 4. 

39. Foundling and Medical Institutions for Children at Vienna. — 
Ibid. 

40. Schreber, M., on the Therapeutical Use of Sun-Baths, particularly 
in certain Chronic Diseases of the Infantile Age. — Ibid. 3. 

41. Schuller, on the Abuse of Syr. Diacod. in Diseases of Infants. — 
Wiener Zeitschrift. 50. 

42. Joachim, W., on the Use of the Laudanum in Diseases of Infants. 
— Ungar. Zeitschr. 32. 

43. Pollard, Th., Use of Opium in Children.. — Atlanta Jour. Nov. 

44. Meigs, J. F., on Semiotics and the Examination of Sick Children. 
— Jour. f. Kinderkr. 2. 

45. Politzer, L., Critical Review of some Opinions an Infantile Pathor 
logy and Therapeutics. — Wien. Med. Wochenschrift. 47. Oesterr. 
Zeitschr. f. Prakt. Heilk. 46. 

46. Scliauenstein and Spath, on the Transition of Medicines from the 
Circulation of Pregnant and Nursing Women into Milk, Amniotic 
Liquor and Foetus. — Jahrbuch f. Kinderkr. II. 1. 

47. Ploss, H., on the Causes of Sexual Difference in Infants. — Monat- 
schrift f. Geburtsk. May. Pamphlet. 

48. Jacobi, A., Report on the Progress of Infantile Pathology and 
Therapeutics. — N. Y. Jour. Jan., March, May, July, Nov. 

49. Jacobi, a Critical Examination of all the Recent Works relating to 
Infantile Pathology and Therapeutics. — N. Y. Jour. Nov. 

50. Thomson, J. B., on the Comparative Influence of the Male and 
Female Parent upon the Progeny. — Ed. Med. Jour. Dec. 

51. Edgren, Swallowing Needles. — Jour. f. Kinderkr. 3, 4. 

52. Silvester, H. A., a Contribution to the Science of Teratology. — 
Med.-chir. Trans. XIII. 

53. Kuhn, on the Origin of Monstres per defectum. — Bull, de l'Ac. 
XXJ1I. Sept. 

20 



306 

54. Joseph, on Double Malformation. — Abhand. d. schles. Ges. 
XXXV. 

55. De Garzia, A., Contributions to the History of Malformations. — El 
Siglo Med. 255. 

56. Schmidt, J. B., Congenital Malformations among 839 births in the 
Clinique of Prof Scanzoni. — Scanz. Beitr. III. 

51. Schultze, B., Cases of Malformations. — Schmidt's Jahrb. Nov. 

58. Martini, on Surgical Treatment of Congenital Malformations; 
Atresia ani ; Obliteratio llei ; Spina Bifida. — Ibid. 

59. Budd, Ch. A., a Case of Unusually Large Development of the Human 
Foetus. — Am. Monthly. March. 

60. Ramis and Breslau, a rare Case of Double Malformation Xiphody- 
mia. — Bayer, arztl. Intellig. 

61. Geoffroy St. Hilaire, Monster ; Xiphodyme. — Gaz. Hebdom. 4. 

62. Girard, on a 3Ionster, Xiphodyme. — Un. Mdd. 136. 

63. Johnson, S. P., a Curious Monstrosity. — Virg. Med. Jour. Nov. 

64. Jackson, J. B. S., Two Foetuses United, Face to Face, from the 
Umbilicus to the Upper Third of the Sternum. — Bost. Med. Jour. 
May, 14. 

Of the manuals of Dr. Hennig, Prof. Condie, and Prof. Meigs new edi- 
tions have been published ; the introductory chapter to the work of 
the last writer, on clinical examination of children, has been trans- 
lated into the German language, and printed in the " Journ.fur Kin- 
derkrarikheiten." It is of a similar scientific value, and practical im- 
portance to that exhibited by Dr. Mayr, of Vienna, in his article on 
examination of sick infants, in which the semiotical signs taken 
from forehead and physiognomy are treated of. We regret to state 
that a new manual on diseases of children, has also appeared and 
swelled the number of those already in existence ; we regret it, be- 
cause an inclination to collect, destroys or lessens the tendency to 
produce. We may confidently assert that the larger the number of 
manuals issued, the greater the dearth of new facts and real scientific 
discoveries ; at all events, it is true, that a small monograph or a 
short, but original article in a medical journal, is to be valued higher 
than a large manual destitute of new facts and the most recent dis- 
coveries like that of Dr. Tanner. We regret th%t it is our duty to 
notice a book, which does not at all meet the demands of the time in 
and for which it has been written. We the more regret it, because 
we have completely to disagree with a highly favorable report in the 
Edinburgh Jour, of Medicine (Aug.), the reports and reviews of 
which we have always been accustomed to hold in great esteem. 
We feel, however, very willing to acknowledge everything that is 
praiseworthy, and therefore we heartily, with the Edin. Jour., give 
Dr. T. credit for limiting excessive bloodletting in infantile diseases ; 
but we deny him the originality in these views which the Edin. Jour. 
claims for Dr. T., and which Dr. T. claims for himself. The .same re- 
marks which the Edin. Jour, is at the pains of reprinting, may be 
found just as well expressed in any good manual on diseases of chil- 



307 

dren, and much better, we think, in Dr. John B. Beck's Essays on In- 
fant Therapeutics (New York, 1855, pp. 82-100). 

A commendable feature of the work is the large number of sub- 
jects treated of, as but very few of the many manuals on diseases of 
children are complete. This deficiency is a great defect in a book 
designed to give full information on any subject that may occur in 
practice, and is not only found in our own American manuals, by 
Meigs, Dewees, and Bedford, but in those also by West, and even 
Rilliet and Barthez ; this latter work should rather be considered a 
collection of most excellent monographs, than as a complete manual. 
While thus acknowledging the completeness of Dr. Tanner's book as 
regards the range of subjects considered, we have to confess that 
there is scarcely one article in the whole collection agreeing with the 
results of modern science in general, and of paediatrics in particular. 
We shall cite only a few examples, from which our readers may draw 
their own conclusions. Atelectasis pulmonum (p. 308) has no other 
cause attributed to it by the author than bronchitis. In his opinion, 
pleurisy in children (p. 305) is most frequently produced by the ex- 
tension of the inflammatory action in pneumonia, while it may be 
considered as certain, that the most obstinate and fatal cases of 
pleurisy very frequently are not even combined with pneumonia. 
Again our author asserts that laryngitis, pneumonia, and pleurisy 
are not unfrequent, while bronchitis and croup are perhaps, of all the 
severe affections of childhood, those which are most commonly met 
with, when, in fact every practitioner is accustomed to meet with 
many cases of bronchitis and pneumonia to a single case, except 
during a severe epidemic, of genuine croup. And it is well known 
that pleurisy and pneumonia do not rank equally as to the frequency 
of their occurrence. In the opinion of Dr. T. again, "Croup is most 
common perhaps during the second year of life," (p. 282), and where 
he is enumerating (p. 284) the indications and contra-indications of 
tracheotomy, he says : "The practice of auscultation in the second 
and third stages, yields information as to the amount of air entering 
the lungs, and the extension or not of the inflammation to the" bron- 
chial tubes and lungs." These assertions are by no means true, not 
even approximatively. The first one may readily be refuted by sta- 
tistics which constantly prove, that (primary and secondary croup 
taken together) croup is less frequent in the first two years of life, 
than in the period from two to five years. Further, whoever has at- 
tentively observed the stages of croup, is well conversant with the 
fact, that in almost all cases it is more than difficult, even impossi- 
ble, to learn the state of the lungs, because no pulmonary sound can 
be perceived on account of the overwhelming noise in the larynx. 
What, again, are we to say of the symptomatological accuracy of a 
writer, who calls (p. 223) "a continued contagious fever, accompanied 
by an eruption, and frequently attended with inflammation of the 
mucous membrane of the respiratory organs," the distinguishing char- 
acter of measles ? Or what of his nomenclature, when with him 
(p. 230) , " simple or infantile, or remitfent, or more correctly, typhoid 
fever" are synonyms? What estimate shalT we place upon the sci- 
entific attainments of an author who, in a book written for the infor- 



308 

mation of others, has only the following to say on typhus in children : 
"Typhus is, Ibelieve, contagious?" or of his knowledge of pathology, 
•who ventures to call infantile intermittent fever "a rare disease in 
children under five years of age?" or of his physiological learning, 
when amongst the four general effects of abstraction of blood from 
the system the first is said to be the diminution of the quantity of 
blood, and another, the weakening of the heart's action ? 

We must add, that we can but find fault with a sentence like the 
following (p. 304): "Either the inflammation terminates in resolu- 
tion and complete recovery, or the roughened surfaces become adhe- 
rent, or they are separated by the effusion of serum, and a kind of 
dropsy results, known as hyilrothorax" — in which the terms are as 
badly selected as the pathology is incomplete or false. Moreover, we 
desire to state, that the general opinion expressed on diseases of 
childhood is not fully according to truth. For example, the author 
states (p. 20), that, "the maladies of this time of life are severe and 
insidious in their nature, soon give rise to organic change, and run 
their course with a rapidity not seen in the adult." This is true, but 
the contrary is equally true ; that the maladies of childhood, severe 
and insidious though they appear to be, do not give rise to organic 
change, but yield readily to health and cheerfulness. Such is the 
action of the nervous system, and the rapidity of metamorphosis in 
the organism of children, that sometimes an extremely doubtful prog- 
nosis is refuted by an unexpectedly speedy recovery, and vice versa. 
A practitioner yielding to the impression communicated by the above 
quotation from Dr. Tanner's work, would be liable to many mistakes 
in his estimation of the importance of apparently dangerous symp- 
toms. 

We have not spage to extend our criticism, and will merely add 
that the author has, by no means, given to individual subjects the 
space and consideration which they deserve. We have spoken of 
atelectasis pulmonum, so prominent a feature in the investigations 
and studies of European writers, which is dispatched in a few lines. 
Tuberculosis occupies only two pages ; scrofula only three and a 
half ; syphilis only one .and a half, while the symptomatology of this 
latter important disease is more defective and inaccurate than almost 
anything in the whole book. Finally, we have to state, that the ex- 
tracts given above are taken at random ; they are not a few points 
selected after a careful reading, but they were generally found on 
the first page wherever we happened to open the volume. 

After the Journal fur Kinderkrankheiten (Journal for Infantile Dis- 
eases), edited by Drs. Fr. Behrend, and A. Hildebrand, and published 
at Erlangen, had been existing for thirteen years, Dr. Kraus, of Vi- 
enna, undertook to publish, also in twelve yearly numbers, the' Oes- 
terreichische Zeitschrift fur Kinderheilkunde (Austrian Journal for In- 
fantile Pathology). When he was, by his private business, no longer 
able to attend to its publication, it ceased^ to appear after two years 
had elapsed, Sept., 185T. Drs. Fr. Mayr, L. M.Politzer, and M. Schul- 
ler, have since stepped in to fill the void, with the Annual for Infan- 
tile Pathology and Physical Education, six numbers of which have 
since appeared. While no other country has a single journal 



309 

for the specialty in question, Germany can boast of two journals de- 
voted to infantile pathology, both of which have alike able contribu- 
tors, and a large number of friends and readers. The contents of the 
Annual are composed of original contributions, miscellanies from 
general medical literature, and critical reviews. The first are most 
valuable. As instances, we name Prof. Clar's essay on the pathology 
and therapeutics of some of the most important disease of the infan- 
tile intestinum crassum ; Dr. Vogel's contributions to the physical 
exploration of the lungs in young infants ; Dr. Mayr's articles on the 
examination and semiotics of sick children ; Dr. Herman Zeissl's 
essay on congenital syphilis of new-born infants and nurslings ; Dr. 
Bokai's article on retropharyngeal abscesses in children ; Dr. Politzer's 
treatise on scientific dietetics and physical education ; and Drs. Frie* 
dinger's, Mayr's, and Zeissl's essay on syphilides of the infantile age. 
The care and industry given to each of the six numbers which have 
hitherto appeared, has been the very same from the beginning to the 
end. The editors cannot but win by their labors the thanks of the 
profession and a good reputation for themselves. 

Dr. Cumming's articles " on a substitute for human milk," and " on 
natural and artificial lactation," are as able as they are earnest. A 
few of his statements will be deemed sufficient to prove this asser- 
tion I An infant three months old will take from forty-eight to 
sixty-four fluid ounces daily, in six or eight half-pint doses. During 
the first year, therefore, he will take from 1000 to 1300 pounds, in 
which the weight of butter is 21 pounds, casein 18.5, sugar 97.5, 
water 1157, salts 2.1 pounds ; of these latter, 12 ounces are phos- 
phate of lime. It thus appears, that during the first year, the child 
receives from 110 to 143 pounds of dry solids. He may thus readily 
gain 15 or 20 pounds in weight, implying less than three pounds of 
dry solids, and yet have a large residue to be expended in the pro- 
duction of heat, and in the activity of an energetic vitality. A child 
thus nourished, can make teeth and bone without difficulty. A 
woman in fully nourishing her child, must furnish as much milk in 
proportion to her weight as a good cow ; a woman weighing 130 
pounds, will give daily 4 pounds of milk, containing about 5 ounces 
of dry solids ; the cow weighing six times as much, will give 6 times 
as rnuch, containing 30 ounces of the same. In an ordinary parturi- 
tion, a woman loses not more than 20 pounds, containing less than 
3 pounds of dry solids ; this amount furnished in nine months, is at 
the rate of 4 pounds a year. Many women fail to furnish fully even 
this small amount ; the infant at birth being small and meagre, 
looking like a starveling. If unable to furnish this small amount, 
how can a mother be expected to furnish 30 times as much ? 



( Butter, 38.59 I ( Butter, 20.76 

Cow's milk J Casein, 40.75 Human milk J Casein, 14.34 

contains. } Sugar, 53.97 contains. ) Sugar, 75.02 

( Water, 866.69 I (, Water, 889.88 



It is thus evident, that by no mode of dilution, can ordinary cow's 
milk be made a substitute for human. There will be in every case 
an excess of casein, or a deficiency of butter. As long as the but- 
ter is to the casein as 100 to 115, instead of 100 to 70, so long must 



310 

dilution fail to adapt it to the wants of the child. But if this origi- 
nal proportion could be changed to that existing in human milk, we 
might have hope of success. If we leave at rest for four or five 
hours ordinary cow's milk, and then remove and examine the upper 
third, we -find in it 50 per cent, more butter than it at first contained. 
In round numbers, its butter is no longer to its casein as 100 to 105, 
but as 150 to 105, or as 100 to 10. If then, by dilution of this milk, 
we reduce the butter to 20.16, we have 14.34 of casein, as in human 
milk. Another mode of obtaining the same result, is by using. the 
latter half of the milk furnished by the cow. The former half con- 
tains 22.18 of butter to 41.63 of casein, while the latter half has 54 
of butter to 38 of casein ; here again the right proportion exists. 
The actual composition of this latter half, is butter 54, casein 38, 
sugar 53, water 855. By adding sugar 142, and water 1458, we 
have butter 54, casein 38, sugar 195, and water 2313, or in pro- 
portion butter 20.71, casein 14.61, sugar 75, and water 889.62 ; the 
difference from human milk is unworthy of notice. 

To imitate colostrum, we must, during the first month of the 
child's life, use milk, containing from 75 to 80 thousandth of butter, 
or from 94 to 107 per cent, more than the ordinary milk of the cow. 
This rich milk may be obtained, by taking the upper eighth instead 
of the upper third of milk left to repose for four- or five hours. It 
may be also obtained by using the last tenth of the milk furnished 
by the cow. 



For a child from 3 to 10 days old. 


Milk 1000. 


Water 2643 


Sugar 243 


u 


10 to 30 


M 


'" 2500 


" 225 


U 


1 month old. 


(1 


• 2250 


" 204 


ti 


2 months old. 


« 


" 1850 


m 172 


II 


3 


u 


" 1500 


ii !44 


K 


4 


It 


" 1250 


" 124 


<( 


5 


« 


u 1000 


" 104 


« 


6 


II 


" 875 


" 94 


(.' 


7 


<( 


" 750 


" 84 


K 


9 


K 


" 675 


" 78 


U 


11 


(1 


« 625 


" 73 


u 


14 


M 


" 650 


" 67 


a 


18 


a 


" 500 


" 63 



In genera], it is better to begin with milk more diluted thaj| the 
age and development would seem to indicate, and then gradually in- 
crease its strength. It is better that the food should be insufficient 
than that it should be indigestible. A child ten days old will take 
about 32 ounces daily in eight four-ounce doses ; the doses will in- 
crease in size and somewhat diminish in number, so that at 3 months 
seven eight-ounce doses are usually taken. The milk should be 
given at regular intervals ; the child should be trained to pass six 
or eight hours at night without feeding. The temperature should 
be from 100° to 104° ; ten or fifteen minutes ought to be given to 
each dose. This food thus administered, may well be styled artificial 
human milk. 

Dr. Politzer tries to find a scientific basis of infantile dietetics, by in- 
vestigating into the peculiarities of the metamorphosis of the sub- 
stances of the infantile organism, and the proportion of gain and 



311 

loss, by exploring the exact nature and faculties of the digestive 
organs, and of the food most in use for children. In his opinion, 
metamorphosis of substance in the infantile organism, is particularly 
modified by the incompleteness of the body, and the chemical and 
physical difference produced thereby of infantile organs in propor- 
tion to those of adults. The osseous system, muscles, and skin, are 
most apt to show such a difference. There is another species of 
glue—- cartilaginous glue — and less lime in the infantile bones than 
in those of adults, but more chloret. sodii, this having a greater 
affinity to the glue of cartilages ; infantile muscles contain more 
albumen, less fibrin, and assimilate from the blood a larger amount 
of salts of^potassa and magnesia than of lime ; this forming no larger 
part of the muscles, until a more powerful respiration, and a greater 
amount of oxygen in the blood favors the formation of fibrin. The 
skin, too, contains more albumen than in adults. Respiration is ac- 
celerated and less energetic, sleep of longer duration ; according to 
the results of physiological science, therefore, less carbonic acid is 
exhaled, less urea excreted. Motions of the body are but few, men- 
tal activity inconsiderable. In the circulation, there are also some 
peculiarities, the heart being less powerful, and the "aspiring" 
effect of feebler inspirations on the veinous blood less consider- 
able. Nor has the relative inactivity of infantile muscles much effect 
on general metamorphosis. Milk undoubtedly changes the ratio 
of its elements according to the period of nursing, but not at all in 
such a degree as albuminous, fatty, and saline elements are changed 
in the food of adults. Finally, digestion, resorption, the size and in- 
fluence of the liver, are of peculiar importance in the infantile organ- 
ism. The practical consequences of the foregoing facts are easily 
understood ; the assimilation of food will have more than only to re- 
store the loss ; it ought to be as digestible as its amount sufficient ; 
proteinates ought to outweigh fats ; lime, potassa, phosphates, are 
required in large quantities, and the food ought to be equable and 
appropriate to the age. 

The further expositions of the author contain a full review of the 
physiology of the digestive organs, as applied to the infantile age. 
The organs of mastication, the stomach, intestines, liver, spleen, and 
pancreas, are treated of ; the digestive power of the infantile saliva, 
gastric, paucreatic and intestinal juice, and of the bile, further the 
digestion of amylacea and carbonhydrates, of proteinates, of fats, and 
finally, the process of resorption of the digested masses, are scientif- 
ically examined. Thus the physiological knowledge of infantile 
digestion, we dare say, is materially improved by the accurate and 
ingenious essay of the author. 

Dr. Routh arrives at the following conclusions as to the diet of chil- 
dren : — 1. The analogy of comparative anatomy of a child's alimen- 
tary canal, indicates that its food should be animal. 2. The child 
should not be weaned, if it can be avoided, before the 8th month. At 
this period it may be allowed to give vegetable food, but animal is 
better. 3. The vegetable aliment* selected should contain chloride of 
potassium and phosphoric acid among its mineral ingredients, and a 
due proportion of plastic as compared with calorifiant matters ; 



312 

excess of starch being very difficult of digestion. 4. If pap be 
given, it should be made with milk, so as to include fat and chloride 
of potassium in the compound, and not given in large quantities ; 
above all, it should not be made with white, town-made bread, which 
contains alum, and is nothing better than a slow poison. He ex- 
presses the opinion that, amongst the vegetable substances, that 
which comes closest to milk in its composition is, without doubt, 
lentil powder, or, as it is called for the purpose of obtaining a better 
sale, Revalenta Arabica, containing both phosphoric acid in abund- 
ance, and chloride of potassium ; it also includes casein, the same 
principle which is found in milk in its constituent parts. Moreover, 
its nutritive matter is to its calorifiant matters in the proportion of 1 
to 2£, milk being in that of 1 to 2. 

Dr. Patron gives but a compilation of what is generally known on 
nursing, its utility to mother and child, its troubles and difficulties, 
its duration, on weaning, and on the diet of the newly-born. 

Generally, the majority of books on dietetics of infants do not form 
a part of the library of medical practitioners, who usually have 
neither time nor inclination to read whatever is written for the 
public. Now, we do not contend that all the numerous books pub- 
lished on this subject ought to be read by the profession, for the 
purpose of increasing their medical knowledge ; for an exact ac- 
quaintance with physiological facts enables the medical man to draw 
his conclusions for himself. But there is a good reason why every 
physician should read as many popular books on infantile dietetics 
as possible. It is only natural that the public should, in their selec- 
tion of books written on a medical subject, mostly depend upon the 
judgment of their medical advisers ; in this case, the physician is 
placed in the most favorable and agreeable position ; he has not then 
to cure diseases, but to prevent them ; not to act as doctor, but 
as medical friend and protector. Every educated physician has no 
difficulty in deciding what kind, and what amount of instruction may 
be safely recommended in the individual case ; but the very fact, 
that the kind of instruction has to vary with education, position in 
life, and talent, should induce physicians to read as many popular 
works on dietetics as possible. What is most important is, that no 
works be selected in which anything is given not based upon incon- 
testable scientific results ; as nothing is more apt to confuse the 
mind than discussions on scientific subjects not wholly decided upon. 
Whatever, then, is laid before the unprofessional public ought to be 
perfectly clear and intelligible. Therefore, everything relating to 
pathological changes, and the cure of diseases, should not be a 
part of the work we refer to ; when they are given, they are more 
than unnecessary, they are positively injurious, because subjects 
requiring years, to be thoroughly comprehended by the student and 
physician, will certainly not be readily understood by the popular 
mind. These preliminary observations are rendered necessary for 
the purpose of applying a uniform standard to the works under con- 
sideration. 

Dr. Besser has, after having obtained a good reputation, a few 
years ago, by a small pamphlet on the importance of the first days of 



313 

infantile life for the education of infants, come before the public 
with a book, which cannot fail to place the author in the first rank 
among popular writers. His purpose is not only to give a number 
of remarks and prescriptions on physical and mental education of 
children, but to make parents understand why they are given. His 
expositions of generation, embryology, pregnancy, and parturition, 
belong to the best we have ever seen published for the use of the 
public at large. This book is more deserving of being translated 
for the benefit of our country, than any with which we are ac- 
quainted. 

Dr. Gauneau's book treats of the usual subjects of a work of this 
character : such as food, air, temperature, light, exercise, bathing, 
dress, dentition, weaning, etc. Good though a part of the articles 
be, and although we do not desire to detract in the least from their 
value, it is impossible for us to agree with the author in all his 
premises. Among the opinions and doctrines whick we could not 
approve, are the following : ' D.igestion is said to be more active 
during sleep, while physiology is teaching the contrary. The in- 
fant ought to take the breast, according to our author, every hour, 
or at least every two hours during the first four or five days, " as long 
as the milk fever lasts, and weaning never ought to take place, in 
common cases, before 16 or 18 teeth are cut, at 22 or 24 months of 
age ; and in no case to be allowed before the age of 13 or 14 
months." We can no more subscribe to this than to Dr. G.'s asser- 
tion, that generally cerebral symptoms and mania occurring during 
the puerperium, indurations of the breast, degenerating into cancer, 
sterility, leucorrhoea, etc.," are the consequences of mothers not 
nursing their infants themselves ; the author not even undertaking 
to show a physiological or pathological connection, as between cause 
and effect. Finally, sentences like the following do not read well in 
a medical work : "At the same time that physical and moral strength 
are being developed, the organs, too, develop themselves" (p. 13). 
The author does not appear to be entirely convinced of his own 
" convictions," because there is a striking contradiction between the 
following important sentences : " The moral education of the infant 
begins with its birth" (p. 41), and "the infant cannot have habits at 
this early age, its life being too active ; every day new sensations 
are impressed upon its brain, and the preceding ones are forgotten" 
(p. 65). Nevertheless, there are some good views, especially in the 
chapter on moral education, which we sincerely wish every mother 
to know, and the perusal of which has given us a great deal of 
pleasure. 

Dr. Plath's book contains simple and unassuming expositions on 
the dietetics of pregnancy and infancy, presented in an easy, simple, 
and modest manner. The method is somewhat different from that 
generally followed, the author preferring to expound the matter in a 
series of fifty-five letters addressed to a newly married lady. Al- 
though not all of his opinions and directions may be agreed upon — 
the author thinks dentition facilitated by some accompanying erup- 
tion, considers the removarof crusta lactea to be absolutely, danger- 
ous, directs cold in convulsions to be principally applied to the fore- 



m 

head, etc. — we cannot but highly recommend as well the abundance 
of matter contained in this little book, as the manner in which it has 
been written. 

Of Prof. Hufeland's "Advice to Mothers," the eighth edition has 
appeared. 

Dr. Hauschild is not a physician, but a well educated physiologist 
and, moreover, an enthusiastic friend of the subject he is writing on. 
His book is written on the principle, that the cure of sick children is 
naturally the physician's business, but that the care of healthy chil- 
dren and the prevention of diseases is a duty belonging to physicians, 
parents, and teachers, in an equal manner. The work being pub- 
lished for the use of parents and teachers principally, no new facts 
are developed, no physiological theories examined or illustrated ; 
only well established truths are exposed in a clear, simple way, and 
in. such a manner as confers honor on the author for his anatomical 
and physiological learning, and for his knowledge of the scientific 
horizont of the public. Some of his views, for instance, on the patho- 
logical importance of dentition, and of worms in the intestinal canal, 
give testimony of such a ripe physiological and pathological judg- 
ment, as we but too often look for in vain, even in physicians. We 
have no doubt that if many voices like Dr. Hauschild's will be able 
to make themselves heard and understood, the knowledge of infan- 
tile dietetics will make a rapid progress among the public, and 
anthropology applied to the infantile organism will be estimated as a 
popular study in all the classes of the people. , 

Dr. Declat's work treats of the foetus after the seventh month of 
pregnancy and the infant at the breast ; the author considering the 
period of weaning to be but the commencing, for the infant, of a truly 
independent existence, the infant being a part of the maternal organ- 
ism, as long as it depends on the mother for its food. In seven 
chapters the author treats of the mother before her confinement, of 
the infant and the selection of a nurse ; of the birth of the infant ; 
of nursing ; of general rules ; of weaning ; of the most frequent in- 
dispositions, diseases and accidents during the period of nursing and 
after weaning, and of vaccination. He emphatically states that his 
book purports to be but a guide in the hands of mothers, to the end 
of preventing diseases and saving life ; nevertheless he thinks proper 
to enlighten " his professional brethren only," with his views on the 
diagnosis and treatment of croup, which is a disease the author, we 
are sure, will hardly have observed at the early age in question. The 
diagnosis of croup is rendered certain, in the author's opinion, by 
merely inspecting the fauces, pseudo-croup showing scarcely a slight 
redness of the mucous membrane, and croup exhibiting false mem- 
branes. This is untrue even in France, where diphtheritic croup is 
most frequent ; the author himself reporting a case where no false 
membranes were seen in the fauces. His treatment consists of the 
frequent administration of emetics (tart. em. with ipec), and of 
bicarb, sod. or chlor. pot.; and if the disease will progress, respira- 
tion become more sibilant, and aphonia ensue, of performing trache- 
otomy. He objects to cauterization of the fauces and larynx, for a 
pretty curious reason ; not proving, but stating as his " conviction," 



315 

that it will aggravate the disease, produce "a terrible inflammation," 
and often kill at once. The chapter on indispositions, diseases 
and accidents of infants and mothers contains only a few other subjects 
besides croup, viz.: diarrhoea, excoriations of the nipple, burns, cuts, 
falls and muguet. Finally, to wind up with our general opinion on this 
new book on dietetics of infants, we dare say that we have never 
had the opportunity t<f read a more eloquent and enthusiastic eulo- 
gium on the Queen of Spain, to whom the work is dedicated, " wise 
and vast genius in governing nations,'* and her "womanly loving 
heart, which derives from her inspiration the true rays of divinity, 
the tenderness and care for her children," and on her being " Queen 
both by blood and by love ;" but that the book fulfills but incom- 
pletely the promises pronounced in the introduction, contains nothing 
new, and omits a great deal. 

Dr. Schreber is well known to the European profession as a writer 
on both the general pathology and the dietetics, particularly gym- 
nastical exercises of children. His new book is a complete review 
of all the means, both physical and psychical, by which the infant 
may be educated from birth to the adult age j by which its body will 
be strengthened, its understanding enlightened, its knowledge in- 
creased, its temper corrected, and manners and habits formed. The 
author is well aware that education will have to vary in every single 
case, every individual's natural disposition and faculties differing 
from those of another ; but that the rates of education are the same 
for every human being, and have to be applied to individual cases. 
We feel a great satisfaction in meeting at last a physician writing 
on infantile matters, who is at the same time a good psychologist 
and pedagogtfe ; as it is but too true, that writers. on psychical and' 
moral education of children have seldom been physiologists, while 
physicians who tried to teach dietetics and bodily development, have 
seldom directed their attention to psychology. Dr. Schreber's book 
is divided into four principal parts, the first of which treats of the 
first year of life, the " sucking age ;" the second, of the period from 
the second to the seventh year, " playing age ;" the third, of the 
period from the eighth to the sixteenth year, the " learning age ;" 
the last period comprehends from the seventeenth to the twentieth 
year. Each of the corresponding treatises comprehends the author's 
views and remarks on and rules for both bodily and mental develop- 
ment ; and the chapters on food, air, baths, sleep, motion, gymnastic 
exercises, dressing, attitude, habits, cultivation of single parts of the 
body ; further, those on playing, on the relations of the child to its 
nurse, to other children, to parents, teachers, and strangers, and on 
cultivation of the character, belong, we dare say, to the best we have 
ever known to be laid down in a book, proving the author to be both 
a learned and a thinking gentleman. The diction is, in the average, 
clear and plain, but some parts of the book, by their theoretical rea- 
soning and by a diction tasting somewhat of passed by periods of 
German philosophy, will undoubtedly be fully appreciated and re- 
lished but- by well-educated readers. Thus the author's work will be 
more found in the hands of. the better classes, of reasoning parents 



316 

and teachers, than of the large majority of the people, who want to 
be instructed easily, plainly, quickly, and cheaply. 

Schopf Merei's and Whitehead's report treats of 1,548 sick children 
attended during 21 months ; its most interesting feature are the 
notes on the patients' mothers, residences and alimentation. On 122 
children, of from 9 months to 3 years of aga whose nutrition and 
bodily development was accurately recordea, the following facts 
were obtained : 

The bodily development was 

I. — 120 children were nursed by their ^[ middling. bad. 

mothers alone, without any artificial In 71 (60 p.c.) 31 (25 p.c.) 18 (14$ p.c.) 

food, for 9 months or longer. 
II. — 68 were nursed by their mothers from 

6 to 9 months exclusively and were 35 (51 } 20 (30 pc<) 13 (19 p . c .) 

afterwards partially fed with milk and v r . v 

bread, etc. 
III. — 216 were not exclusively nursed by 

their mothers, but had artificial food 110 (51 p.c.) 54 (25 p.c.) 52 (24 p.c.) 

intermixed from a very early date. 

IV -£ sz r;s:£ by ar,1Mal » < 28 *-> « < 26 ►*> *» «« •*> 

V.-.0 were not at all nursed by their 4(10pA) 10 (25 p. c .) 28(65 p.e.) 
mothers, or for a very short time only. v r . v. / 

Of 1,548 sick children, 249 were suffering from troubles of the 
digestive functions, 116 from atrophy, 256 from weakness, 74 from 
rachitis, that is to say, 696 suffered in consequence of vicious 
alimentation ; 93 died of this number. Of the whole number of 
1,545, 117 died ; 12 of them were from 3 to 14 years old ; 105 under 
.3 years ; 96 under 2 years ; 47 under a year ; 29 under 6 months. 

Of 186 sick children under 6 months, died 29 



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Two papers, read by Dr. Routh before the Medical Society of Lon- 
don, furnish the following statistics : The mortality amongst young 
children during one year, in Manchester, amounted to 55.4 p. c; the 
corresponding figures for London being 40.2, for Leeds 52, and for 
Birmingham 50 p. c. in the same year. 

In 1857, there died in London 363 children from "want of breast- 
milk ;" and in seven years (from 1848 to '54) the number of deaths 
in all England due to this cause, increased from 393 to 842. Amongst 
the main causes of the large number of deaths occurring among 
young children, Dr. Routh counts the injurious excess to which wet- 
nurses are employed? even such as are by no means able to nurse, 
and the bad quality of the milk, the sale of which ought to be regu- 
lated by the law. ■ 

• The returns of young patients of the London Hospital are of no 
statistical importance, because the 214 cases are only those of acci- 
dent and diseases of the more urgent character. 



317 

The proportion of children dying" under 1 year, to the whole num- 
ber of the population of Berlin, according to Dr. Helfft, was in 

1849 1 : 155. 16 

1852 .' 1 : 139.62 

1855 1 : 140.72 

Of the children who died in the first year, 3.11 per cent, died within 
the first twenty-four hours ; 23.75 from the second day to the end of 
the first month ; 12.01 in the second month ; 10.03 in the third ; 9.47 
in the fourth ; 6.91 in* the fifth ; 6.87 in the sixth ; 5.87 in the sev- 
enth ; 5.32 in the eighth ; 4.48 in the ninth ; 4.18 in the tenth ; 4.05 
in the eleventh ; 4.00 in the twelfth. Hence, the probability of life is 
increasing monthly, even daily. As a general rule, August was the 
most pernicious month at every age. 

Dr. RiEDELL reports some statistical facts on the new-born children 
of Berlin, taken from the records of the years 1846-1855. The pro- 
portion of males to females is 1.0772: 1. Of 23 new born boys, 1 
is still-born ; of 25 girls, 1 ; of new-born infants in general, 1 is still- 
born out of 25. The temperature appears to have a great influence 
upon the sex of infants. The higher the average yearly temperature 
at the time of conception, the larger is the proportion of males to fe- 
males. Conception in Spring is more favorable to the female sex, 
conception in Fall to the male. Temperature, finally, is not only of 
some influence upon the sex, but on the chances of living after birth 
also ; a high average temperature at the time of conception (not of 
birth )^ appearing to augment such chances. 

Dr. Husemann's accurate statistics are of great value. He shows, 
that of newly born children, in the principality of Lippe, from 3.3 to 
4.27 per cent, die in the first six weeks after birth. Of the children, 
born alive, 15.54 per cent, will die under two years of age (in Bel- 
gium 29 per cent, according to Quetelet's reports) ; of the whole num- 
ber of deaths 2,1.6 per cent, occur at this age. It is to be noticed as 
a remarkable fact at once, that this rate of mortality has been about 
equal for the last seventy years. Of the whole number of deaths 
9.1 per cent, occur from 2 to 5 years of age ; 5.12 per cent, from 5 to 
10 years.' This proportion was much more unfavorable in the periods 
of 1788-1807 (7.5 per cent ), and of 1808-1822 (5.7 per cent), be- 
fore and after the first introduction of vaccination. Of the whole 
number of deaths, 5 per cent, occur at the age of from 10 to 20 
years. 

Dr. Schf.rzer states, that the mortality of children in China, is at 
least as high as in Europe, perhaps even larger. Variola and tetanus, 
dysentery and cholera, are frequent and very dangerous. M.any cases 
of intermittent fever came under observation in the age of from 8 
to 20 years. 

According to the Report of the Hospital for sick children, Ormond 
Street, 1857 ; of the whole number of children of the better classes 
in England, from 25 to 30 per cent, die in the first ten years of life, 
of the lower classes from 30 to 40 per cent., and as many as 60 or 70 
per cent, under peculiar epidemical influences. Mortality among 
children at London, is but 2 per cent, less than fifty years ago. Of 
50,000 deaths in London, 21,000 die under 10 years of age ; in the 



318 

eight largest cities of Scotland, of the whole number of deaths 46.5 
per cent, occur in the first five years of life. In Ireland, 18 per 
cent, of the deaths occured under five years of age, less in the coun- 
try (in some counties 14 per cent, only), more in the cities ; thus in 
Gal way, 20 ; in Dublin, 20.2 ; Kilkenny, 20.3 ; Waterford, 21.5 ; Lim- 
erick, 22.1 ; Belfast, 22. 1 ; Cork, 23.5 ; and Drogheda, 25.5 per cent. 
In France, of 100 newly born children, 20 males and 16 females will 
die in the first year, that is to say, a fifth part of the males, and a 
sixth of the females. In some of the English colonies, the rate of 
mortality is highly unfavorable ; during the summer, at Melbourne, 
there are scarcely more births than deaths, in the course of six 
months, in 1853, the number of deaths was even twice as large as of 
births ; in 1857 there were TO deaths in children under a year, to 100 
newly borti children. 

Some of the facts observed by Dr. Hauner are exceedingly inter- 
esting. For the months of September and October, 1856, a similar 
weather and a like temperature prevailed; nevertheless bronchial affec- 
tions were numerous, and very much so, in the course of October 
only. The temperature of October, 1857, was very much like that 
in 1856, but bronchial affections were very rare occurrences. Hoop- 
in cough was influenced, in 1857, neither by season nor by tempera- 
ture ; typhoid fever occurred in the same monthly number during the 
whole year, December excepted, where no case occurred. In Feb- 
ruary and March, without any particular changes in the atmosphere 
being observed, inflammations of the parotis were very frequent. 
Acute exanthems occurred in every month ; and infantile cholera and 
slight dysenteries were observed, as well in December as July. Dr. 
Hauner's therapeutical remarks are accurate, but naturally do not 
contain much that is new. Hooping cough was treated more suc- 
cessfully, than by any other class of remedies, by narcotics, morph., 
aq. lauroc, extr. bellad., and in later stages by chin>, lich. island. 
Diseases of the liver were sometimes found in post-mortem examina- 
tions, where they were very little thought of ; fat-and nutmeg-liver 
were the most frequent anomalies found, particularly in rachitical 
children suffering from d} r spepsia and intestinal catarrhs. Dysuria 
was met with several times ; in the majority of cases, the cause ori- 
ginated from the influence of cold, some of superabundance of uric 
acid. Incontinence of urine was observed in a boy of five years ; 
the disease depended on weakness of the neck of the bladder, and 
was successfully treated by appropriate diet and posture, local ap- 
plication of cold, and cold hip baths. Diphtherite of the vagina was 
observed jn a healthy girl of 1\ years ; local application of nitr. arg., 
and the administration of the chlorate pot. proved successful. Fluor 
albus was observed in four little patients, who were cured by a gen- 
eral antiscrophulous treatment, baths of chamomile flowers (chamom. 
vulg.), and application of Goulard's water. A case of tuberculous 
inflammation of the petrous bone ended fatally, by tubercular disease 
of the brain. Rachitis will in almost every case be cured by cod- 
liver oil ' T iron, so highly recommended by some writers of Vienna, 
proved proportionately unsuccessful. 

Prof. Loschner's, of Prague, report on the Children's Hospital and 



319 

Dispensary, is of but little scientific interest. Among 911 patients 
of the Hospital, the mortality was but 10 per cent., in spite of epi- 
demics of measles and scarlet fever. 

The report on the Children's Hospital in Great Ormond Street, Lon- 
don, which was founded by Dr. West, is painfully interesting. The 
number of beds in 1857 were 31, though the number of 100 beds was 
originally contemplated. The funds were nearly exhausted. 

The reports on Continental Children's Hospitals, are uninteresting ; 
as they do not contain anything except some meagre notices on the 
Hospitals of Berlin, Frankfort, and Prague. 

The Children's Hospital of Graz (Austria), has had, in the twelve 
years of its existence, 1,803 patients, of whom 1,311 were dismissed 
cured, and 236 (13 per cent.) died. A large number of patients 
suffered from scrofula and rhachitism (260), catarrhal affections of 
the respiratory organs and intestines, and inflammatory diseases of 
the lungs. Cases of croup were, in 12 years, 8 ; acute hydrocephalus 
5, of which one was saved. 

The Foundling Hospital of Vienna received, in 1856, 9,228 infants, 
of whom 2,105 fell sick ; 55 per cent, with acute, 45 per cent, with 
chronic diseases. The mortality among the patients was 60 per 
cent. The percentage of diseases »f the several systems is the fol- 
lowing : Diseases of the nervous system, 2 percent.; sensory or- 
gans, 23 ; mouth and fauces, 5.5 ; circulatory and respiratory organs, 
12 ; chyloe'potic system, 20.5 ; urogenital organs, 0.5 ; skin, 6.5 ; 
nutrition and blood, 21 ; external diseases, 9 per cent. Besides, 
there were 6 cases of variola, 1 of measles, 1 of scarlatina, 2 of 
hooping cough. 

There are two Hospitals and 5 Dispensaries for sick children at 
Vienna. The main statistics are given in the following statements : 



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Dr. Schreber exposes children suffering from scrofula, atrophy, bad 
general development without a distinct organic disease, anaemia, 
flabby and pale skin, torpid tumors, osseous swellings, etc., to the 
sun, one, two, three times a day, keeping the child, the head covered, 
from ten to thirty minutes (no longer, for fear of erythema) in a room, 
undressed (full bath) or half dressed (half bath). He expects the 
sunbeams to enliven the peripheric nerves both generally and. locally. 

Dr. Pollard advocates the use of opium in cautious doses, as he 
considers the objections to its administration in diseases of infants 
unwarrantably magnified by some writers. Generally, opium is 
much dreaded in diseases of infants, for its dangerous effects on the 
cerebrum and meninges. We think that it must be dreaded when 
given without strict indications, but will easily be tolerated whenever 
it is not applied unscientifically or wantonly. 

Dr. Politzer has expressed, before a Medical Society at Vienna, his 
views on several important points concerning infantile pathology, of 
which we select the following : High rate of mortality is no physio- 
logical consequence of infantile nature, but is produced by accidental 
obnoxious incidents. On the contrary, things are even more favor- 
able in infancy, the causes of diseases increasing in number and 
severity with advancing years, and the frequency of so-called infan- 
tile diseases being greatly overrated. Typhus, pneumonia, and mor- 
billi give proof of the readiness of recovery in children ; but diarrhoea 
is very dangerous. Diseases from teething and worms do not exist. 
Emetics and purgatives are much misused, so are leeches ; opium re- 
quires great care and caution. Constitutional diseases ought to be 
treated in early age, and never overlooked indifferently ; iron is espe- 
cially indicated in the chronic form of rachitis ; acute rachitis is fre- 
quently 'mistaken for some other trouble. Suppression of chronic 
exanthems is by no means dangerous ; diaphoresis never ought to be 
resorted to for the purpose of reproducing an exanthem that has dis- 
appeared. 

Dr. Schauenstein's and Dr. Spath's careful examinations have re- 
sulted in the following facts, viz., rhubarb was found in the breast- 
milk, sulphate of potassa was not. Iodine was proved to be present, 
after having been taken by pregnant and nursing women, in the 
meconium of the foetus, in the urine, milk, and amniotic liquor during 
pregnancy. The chemical signs of mercury were not discovered with 
any degree of certainty. 

Dr. Ploss, after reviewing former opinions on the subject, tries to 
arrive at a result from a great number of exact statistical reports. 
The principal conclusion he draws, and found very rarely refuted, is 
this, that the sex of the children born during a year is in a strict 
proportion to the dearth and consumption of bread and meat. The 
number of males will always increase with the scarcity and dearth of 
bread and meat, while in those years where these victuals are 
copious, the number of males is less. Such is Dr. Ploss' con- 
clusion, arrived at, not only by statistical comparisons of different 
nations or districts, but of the same localities or populations in differ- 
ent years. It is to be kept in mind, however, that at all events the 
number of newly-born males is always and everywhere absolutely 
21 



322 

larger than of females, and that, therefore, the above stated conclu- 
sions must not be considered but in regard to the relative number of 
females and males. 

Mr. Thomson arrives at the conclusions : 1. That in the lower 
animals, and in man also, the influence of the male is greater than 
that of the female parent,, in the transmission of the skin texture to 
the progeny. 2. That the exceptional cases (probably more in man 
than in the lower animals) lead us to look for some primary or 
secondary law presiding over the physiology of generation. 

Dr. Edgren reports two cases of children swallowing needles 
without unfortunate consequences. A boy, three years old, . swal- 
lowed a needle two and one-half or three inches in length, which 
a month later penetrated the skin, near the sternum, from beneath 
the pectoral muscle. A boy of four years of age, swallowed a large 
pin with a big head, the head going down first. On the third day 
after, there was pain in the right side, about the region of the pylo- 
rus and duodenum. On the eighth day, the head was removed from 
the anus, only an inch of the pin being in connection with it. 

Mr. Silvester draws, from a large number of cases observed by him, 
a series of conclusions, of which the following are the most import- 
ant : 1. The deformity appears to be the result of, first, the malforma- 
tion of the germ ; secondly, the subsequent deformation of the 
embryo and foetus, by causes operating on its development : and, 
thirdly, by certain compensations and vital accommodations having 
a conservative tendency. 2. The arrest of development reacts on 
various parts of the body, and particularly on such parts as have 
either a casual or a natural connection with the original malforma- 
tion. 3. A law .of compensation prevails during the growth of 
monsters, consisting in a tendency to render the parts as nearly nor- 
mal as possible, and to make up by excessive formation for the defec- 
tive development of an adjoining part. 4. The several parts of the 
body are formed and developed independently of each other. 5. The 
muscles are directed to fixed points of attachment, and in the most 
nearly regular way possible under altered circumstances. When a 
bony insertion is unattainable, they unite together by their tendons ; 
there is a vital accommodation to the exigency of the case. 6. The 
absence of the usual bony attachment, or the want of a firm point of 
insertion, exerts a material influence upon the development of a 
muscle. 7. The absence, or defective state of an organ, reacts un- 
favorably upon the formation of the nerves and vessels which supply 
it, even at a distance. 8. The deformity in the arm does not conform 
to the rule laid down by Rokitansky : " When the radius is wanting, 
the thumb and forefinger, with so much of the carpus as belongs to 
them, are wanting too." 

Among the congenital malformations observed in the clinique of 
Prof. Scanzoni were : 1. Fractures of the bones of all the four ex- 
tremities. The right forearm was fractured just above the carpal 
joint, the left a little higher, either of the femora above the condyli, 
the left leg above the ankle. The arms were kept bandaged, the 
lower extremities were left to nature. A cure was effected within 
eight weeks. 2 Absence of the soft palate, and coherence of the 



323 

last two toes of the left foot. 3. Supernumerary thumbs. 4. Cases 
of atresia ani, both epidermoid and membranous. 5. Insufficiency of 
the bicuspidal and tricuspidal valves, which was diagnosticated be- 
fore birth, by Prof. Scanzoni. 

Dr. Martini gives a review of the recent progresses of the surgical 
treatment of congenital malformations, such as imperforate anus, 
obliterated ileum, and spina bifida. None of his facts and extracts 
belong to the year .1858. Such is also the case with the cases col- 
lected by Dr. Schultze. 

Dr. Budd describes a foetus, perforated and extracted by means of 
the crotchet, twenty-three and one-half inches long, and weighing a 
trifle over twelve pounds. The measures of the cranium are of little 
moment, as the bones were broken and cerebral suflfctance evacu- 
ated. 

Drs. Ramis and Breslau report the case of a woman of thirty-nine 
years, who had borne three children ; the youngest one, one and one- 
half years old. The fourth pregnancy took a regular course, being 
troubled by neither bodily nor mental affections. She brought, with- 
out artificial means, a xiphodyme, with two heads, two thoraxes, four 
humeri, four arms. The two xiphoid processes cohered closely. 
There were only one abdomen, two lower extremities, one umbilicus, 
one set of female genital organs. The monster was born at matu- 
rity, lived eight days, either half like an independent being. Never- 
theless the organs of nutrition appeared to be in connection with 
each other. Death ensued on the eighth day, one dying about 
fifteen minutes after the other, as is usual in monsters of this descrip- 
tion. 

Dr. Johnson has observed the case of a child born at maturity, 
and living for half an hour, who was large and perfectly well- 
formed from the attachment of the cord upwards. " From the navel 
downwards, there was a gradual tapering. There were no geni- 
tal organs, no anus, and no well marked pelvic bones. At the 
junction of the sacrum, with the lumbar vertebrae, there was an in- 
terruption of the spinal column. A small circular scab covered this 
opening in the spine, andj we suppose, closed the termination of the 
rectum. All the bones of the legs were present except the patellae. 
There was no line of demarcation between the legs, both being 
enclosed in the same cuticle, and one single set of muscles. To this 
double leg, there was attached a single club foot, with ten perfect 
toes." 

Dr. Jackson reports, from the practice of Dr. D. J. Perley, of Old 
Town, Me., the case of two foetuses united, face to face, from the 
umbilicus to the upper third of the sternum, living until about ten 
minutes after birjh. There was but one placenta, and but one funis, 
until it arrived within about two inches of the foetal abdomens, when 
it divided, and a branch went to supply each of the children. The 
following organs were found in each foetus, and they were well 
formed : the spleen, two kidneys, with their renal capsules, the blad- 
der, and the testicles ; all four of the latter being in the abdomen. 
Penis of each large. Vesiculse- seminales of each well developed. 
Pancreas of one, " felt, but not dissected." The heart was single, but 



324 

formed* by a fusion of two, and contained in a single pericardium. 
Its transverse diameter was much greater than the longitudinal. 
Between the. two right auricles there was nothing like a septum ; the 
left auricles also opened freely into the right. The great vessels 
naturally offered many anomalies as to size and course. There 
were two livers, the whole mass being small for the two foetuses. 
They were intimately fused by their upper edges or extremities, and 
each had its gall-bladder ; in each the umbilical vein entered the 
convexity, and each had its suspensory ligament. The diaphragm 
formed a large arch. There were two distinct pleural cavities, two 
sets of lungs, two tracheas, larynxes, thyroid and thymus glands. 
Weight of the two foetuses five pounds ten ounces ; length fifteen 
and three-foiflfth inches. No hernia at insertion of cord. 



II. DYSCRASIC AND TOXAEMIC DISEASES. 

1. Gabriel, Case of Intermittends Larvata Bihebdomadaria. — Jour. f. 
Kinderkr. 1, 2. 

2. Heidenhain, on Intermittent Fever. — Virch. Arch. XIV. 5, 6. 

3. Craig, J. W., Cerebrospinal Meningitis: Brain Fever. — Buff. Med. 
Jour. July. 

4. Avrard, on Pernicious Intermittent Fever in Children. — Gaz. d. 
Hop. "70. 

5. Jones, C. Hansfield, MaLarioid Intermittent Fever in Children. — 
Brit. Med. Jour. July 31. 

6. Joseph, Case of Intermittens. — Virch. Arch. XV. 1, 2. 

7. Mall, J., Typhus, with Secondary Croupous Inflammation of the Re- 
spiratory, Intestinal and Vaginal Mucous Membranes. — Allg. Wien. 
Med. Zeitschr. 22. 

8. Lebert, New Investigations on the Pathological Anatomy of Abdomi- 
nal Typhus. — Prag. Viert. 1. 

9. Bazin, Er., Lecons TMoriques et Cliniques sur la Scrofule, Consi- 
der tie en Elle-meme et dans ses Rapports avec la Syphilis, la Dartre et 
V Arthritis. Paris, pp. 262. — (Theoretical and Clinical Lectures on 
Scrofula, Considered in Itself and in its Relations to Syphilis, Tetter, 
and Gout.) 

10. Peloly, G. F., Qu'est ce que la Scrofule f Paris. These, pp. 32. 
—(What is Scrofula]?) 

11. Faye, F. C, The Children's Hospital at Christiania in the years 
1855-1857.— Journ. f. Kinderkr. 11, 12. 

12. Masse", Z., Trois Maladies RtpuUes Incurable, Epilepsia, Dartres 
et Scrofule. Paris. IV. ed. pp. 251. — (Three diseases Reputed In- 
curable, Epilepsy, Tetter, and Scrofula.) 

13. Hauner, Report on the Eleventh Year of the Dispensary Connected 
with the Children's Hospital at Munich. — Jour. f. Kinderkr. *l, 8. 



325 

14. Hauner, Therapeutic Notices from the Children's Hospital at 
Munich.— Jahrb. f. Kind. II. 2. 

15. Leriche, de VEmploi de Nouvelles Formules Jodiques comme Suc- 
cedanies de VHuile de Foie de morue dans la Scrofule, et de VJodure 
de Potassiuni dans les Affections Syphilitiques. — (On the Use of 
Formulas of Iodine Instead of God-liver Oil in Scrofula, and of 
Iodide of Potassium in Syphilitic Affections.) 

1 6. Lebcrt, Observation of Scrofula Healed by located Alimentation. — 
Un. Mdd. 124. 

It. Engert, on Tuberculosis and Scrofula in the Infantile Age. — Journ. 
f. Kinderkr. 5, 6. 

18. Rollet, Hereditary Transmission of the Tuberculous Diathesis. — 
Gaz. Mdd. de Lyon. 1£. 

19. Hutchinson, Cancer of the Testicle in a Child. — Med. T. and Gaz. 
May. 

20. Diday, P., Exposition Critique et Pratique des Nouvelles Doc- 
trines sur la Syphilis, Suivie dlune Etude sur de Nouveaux Moyens 
Priservatifes des Maladies Vdntriennes. Paris, pp. 560. (Critical 
and Practical Exposition of the New Doctrine on Syphilis, with In- 
vestigations on New Preservatives against Venereal Diseases.) 

21. De Meric, V., Third Lettsomian Lecture on Hereditary Syphilis. — 
Lane. Dec. 

22. Parker, L., Lectures on Infantile Syphilis. — Lane. Aug., N. Y. 
Jour, of Med. Sept. 

23. Knoblauch, Aerztlicher Bericht uber die Leistungen des Rochus- 
spitales zu Frankfurt a. M., im Jahre 1857. (Medical Report on the 
Results of the Rochus Hospital at Frankfort, in the year 1851.,) 

24. Friedinger, Mayr and Zeissl, on Syphilitic Eruptions in the In- 
fantile Age. — Jahrb. f. Kind. II. 1. 

25. Congenital Syphilis in an Infant a few Weeks old. — Lane. Oct. 

26. Thiry, on Hereditary Syphilis and Syphilitic Induration of the 
Liver. — Presse Me"d. Belg. ,22. 

21. Hutchinson, J., Death from Hereditary Syphilis. — Lane. Aug. 

28. Hutchinson, J., Report on the Effects of Infantile Syphilis in Mar- 
ring the Development of the Teeth. — Trans. Path. Soc. IX. p. 449. 

29. Friedinger, Case of Hereditary Syphilis. — Jahrb. f. Kind. II. 1. 

30. Sigmund, C, Notices on SyphUization as Performed by Dr. Sperino. 
Z. d. Ges. d. A. z. Wien. 46. 

31. Thompson, on Diphtherite. — Brit. Med.* Jour. 75. 

32. Atcherley, on Epidemic Ulcerous Angina. — Brit. Med. Jour. IT. 

33. Heslop, T., on Diphtherite and its Treatment. — Med. Times and 
Gaz. 413. 

34. Martin, Pseudo-Membranous Angina, Extraction of False Mem- 
branes by Means of the Finger, Cauterization with Hydrochloric 
Acid. — Journ. d. Mdd. (Brux.) May. 

35. Barthez, E., on Diphtherite.— Uti. Mdd. 133. 



326 

36. fieale, L., The Structure of Pseudo-Membranes in some Cases of 
Diphtherite. — Arch, of Med. I. 3. 

31. Bouchut, on the Treatment of Diphth. Angina. — Gaz. Hebd. 44. 
G. Hop. 121. 

38. Bouchut and Empis, on Albuminuria in Group and Diphth. 
Diseases.— Un. MeU 132. 

39. Bryden, W. A., on the Treatment of Diphtherite. — Brit. Med. Jour. 
Nov. 6. 

40. Cowdell, Ch., on Epidemic Croup of the Fauces. — Brit. Med. Jour. 
Nov. 20 and 21. 

41. Duche", on the Prophylaxis of Diphtheritic Angina. — Gaz. des Hop. 
125, 133. 

42. Giraud-Teulon, Retrospect on Croupous Affections. — Gaz. de 
Par. 46. * 

43. Mauguin, A., Des Eruptions qui Compliquent la DiphtMrie et de 
V Albuminuric Considirie comme Symptbme de cette Maladie. — Paris, 
Duboisson & Co. pp. 32. — (On the Eruptions Complicated with 
Diphtherite, and on Albuminuria Considered as a Symptom of this 
Disease.)— Mon. d. Hop. 130, 131. 

44. Odriozola, on Epidemic Diphtheritic Angina at Lima. — Gaceta 
Med. de Lima. Julio 15. — Amer. Jour. IV., 520. 

45. Sde and Piogey, on Diphtherite, Croup and Tracheotomy. — Un. 
MeU 154. 

46. Semple, R. H., on Diphtherite. — Brit. Med. Jour. Nov. 5. 

41. Wade, W. P., Observations of Diphtherite. — London, pp. 32. 
Edinb. Med. Jour. Dec. 

48. Ward, T. 0., Cases of Diphtherite.— Turns. Path. Soc. IX. 211. 

49. Harveian Society; Diphtherite. — Lancet. June, July, Sept. 

50. Godfrey, B., Reports of Cases of Diphtherite or Malignant Sore 
Throat. — Lane. Jan. — N. Y. Jour, of Med. March. 

51. Henderson, J., a Case of Cynanche Maligna; Tracheotomy Per- 
formed. — Edin. Med. Jour. Nov. 

52. Brown, B. M., Report of Two Cases of Diphtherite. — Lane. May. 
N. Y. Jour. July. 

53. Camps, the Lately Prevailing Diphtheritic Affections. — Lane. 
May. — N. Y. Jour. July. — Brit. Med. Jour. March 20. 

54. Registrar-General, on Diphtheria. — Quart. Ret. Reg.-Gen. 
March. 

55. Fourgeaud, V. J., Diphtheritis : A Concise Historical and Critical 
Essay, on the Late Epidemic Pseudo-Membranous Sore Throat of 
California (1856-51), with a Few Remarks Illustrating the Diag- 
nosis, Pathology and Treatment of the Disease. — Pac. Med. and Surg. 
Jour. X. (Reprint. Pamphl.) 

56. Blake, J., on Diphtherite. — Pac. Med. and Surg. Jour. VIII. IX. 
51. Diptheritis, the Quinsey Malignant Sore-Throat Prevailing in 

Albany, K Y. — Am. Monthly. Dec. 



327 

58. Fuller, a Fibrinous Cast of the Pharynx, Ejected by a Patient of 
Eleven Years Suffering from Diphtherite. — Trans. Path. Soc. IX. 
206. 

59. Thompson, D., on Dyphtheria, or Diphtherite. — Brit. Med. Jour. 
June 5. 

60. Wilks, Diphtheria and its Connection with a Parasitic Vegetable 
Fungus. — Med. Times and Gaz. Oct. 2. 

61. Laycock, on Diphtheria as caused by the Gidium Albicans. — Ibid. 
May 27. 

62. Hauner, Therapeutical Notices from the Children's Hospital of 
Munich. — Jahrb. f. Kind. II. 2. 

63. Jacobi, A., Report on the Progress of Infantile Pathology and Ther- 
apeutics. — N. Y. Jour, of Med. July. 

64. Kingsford, Ch. D., on Diphtheria. — Lane. Nov. 

65. Santesson, Case of Hydrophobia. — Journ. f. Kinderkr. 3,4. 

66. Bouchut, E., 'on Diphtheritis, Actual Cautery, and Amputation of 
the Tonsils.— Un. MeU 127. 

67. Vigla, Communications Relative to Pseudo-Membranous Pharyn- 
gitis. — Un. Mdd. 115. 

68. Schwarz, F., on Solid Nitrate of Silver in Diphtheritis. — Oest. Z. 
f. prakt. Heilk. 32. 

Dr. Gabriel reports the case of a boy of fourteen years of age, who 
had been suffering, for the last two and a half years, from headache 
and vomiting, every fourteenth day, which was always Tuesday; the 
boy being entirely well the other thirteen days. He soon recovered 
after taking chin, and ac. arsenicos. 

Dr. Heidenhain gives, in an elaborate article on intermittent fever 
in general, his views and experience on what he calls convulsive in- 
termittens, viz., such cases of intermittent fever in children as show 
no other prominent symptoms except convulsions, instead of the 
usual (Symptoms of fever. In the majority of cases only one side is 
affected ; whenever both are, they are alternately. The attacks last 
for 4, 6, 8 hours, without dangerous results, or with paretic weak- 
ness or complete paralysis following. Sometimes in Heidenhain's 
experience, the child died in the second attack — always in the third. 
Death ensues with the symptoms and the pathological alterations of 
hydrocephalic apoplexy ; the commencement of each attack resem- 
bling very much hydrocephalic apoplexy, and ending in sweating, 
with a large or slowly diminishing number of pulsations, and high 
temperature of the skin. The diagnosis is very difficult ; the pro- 
dromi must be carefully weighed, and the epidemic genius consid- 
ered. But it must be remembered, also, that hydrocephalic 
apoplexy is as common in Spring as intermittent. Already, Gblis has 
spoken of an intermittent form of hydrocephalus ; thus this disease, 
and tubercular meningitis, may be mistaken for intermittent fever. 
Dr. H. reports the case of a girl of 9 months of age, who went 
through a sudden attack of convulsions, returning about the same 
hour on the third day ; the last attack appearing less severe than the 



328 

■ 

first. Death ensued after 8 days had elapsed, and the post-mortem 
examination showed purulent arachnitis. During the convulsive 
attack nothing should be done ; some good may be effected by cold 
applied to the head ; leeches are always injurious. 

Dr. Craig reports a series of cases occurring among adults and 
children, of meningitic symptoms invading suddenly and abruptly, 
with chills, followed by prostration, pain in the head and neck, and 
vomiting. The diagnosis was much more certain by a periodicity of 
the disease after it had existed for a few days. All of his cases, 
which were 129, 12 of which proved fatal, occurred at a time when 
there was a prevalence of miasmatic diseases, such as intermittents 
and remittents, of a persistence and severity before unknown. The 
whole course of the disease, and the success of the treatment by 
large doses of quinine and stimulants, proved the miasmatic origin 
of the disease. Death occurred in 5 cases within 36 hours ; in 3 
within 1 week ; in 1 in the 5th week ; in 1 in the 8th ; in 2 after 
several months. The post-mortem examinations " revealed a softened 
condition of the base of the brain and upper portion of the spinal 
cord, with a very copious effusion of limpid fluid in the ventricles — 
in one case amounting to 8, in the other to 12 ounces." Evidently, 
all these cases of Dr. Craig do not deserve the name of " cerebro- 
spinal meningitis," as given by the author, but are cases of intermit- 
tent fever like those of Dr. Heidenhain. 

Thus Dr. Avrard rightly answers the question put by Bouchut, 
Is pernicious intermittent fever ever met with in infantile age ? 
affirmatively ; in declaring at the same time the diagnosis to be more 
difficult than in adults. Troubles of dentition or meningeal affections 
often give rise to mistakes. Two cases are given as illustrations. 

Dr. Jones describes a morbid condition met with in children, not 
entirely corresponding with what is called remittent fever in adults. 
The children have been gradually losing health for several days or 
weeks ; they are languid, drooping, emaciating, and, without appe- 
tite, more or less thirsty. The night is the time of most disorder ; 
there is considerable cerebral disturbance ; in some cases, also, 
copious perspiration. The children may be apyretic during the 
day, but become feverish at night. The bowels may be costive 
or much relaxed. The tongue is clean in some, in others coated. 
Quinine in large doses, was found to be of decided curative efficacy. 
Cod liver oil and steel wine he also sometimes gave with advan- 
tage. He is much inclined to consider these fevers as of malarious 
character, and we do not perceive, indeed, why he should not, be- 
cause, in the series of symptoms enumerated, the high nervous ex- 
citability of the infantile age taken in account, there is nothing 
that would not agree with the symptomatology of so frequently 
indistinct malarious processes. 

A rare ingeniousness is exhibited by Dr. Joseph, in discovering a 
new variety of intermittent fever, viz., the "intermittent worm 
fever." A boy of 2£ years evacuated a large number of oxyuris 
vermicularis, after injections had been given ; for three weeks he did 
not feel well, and finally had two severe attacks of daily intermit- 
tent fever. Dr. Joseph administered santonine, but without, success 



329 

as to the ejection of helminths. Finally, quinine was given, and the 
boy recovered rapidly. This was a case of intermittent worm fever 
in the opinion of the author, while we are surprised at his naivetd. 
and sec in the whole report nothing but a boy evacuating some in- 
nocent helminths, and suffering afterwards from the prodromi, and, 
finally, the attacks of intermittent fever. 

Dr. Mall observed a case of abdominal typhus in a girl of 6 years 
of age, the complications of which are unusually interesting. On and 
after the eighth day of the disease, pseudo-membranes developed 
themselves in the mucous membranes of ^he nose, and went down 
into the larynx, mouth, oesophagus, stomach, intestines, and vagina. 
Local applications of borax and roborant remedies and diet formed 
the principal part of the treatment. The child finally recovered. 

Of all the cases of abdominal typhus recorded by Prof. Lebert, 
ten per cent, occurred in individuals under fifteen years of age. In 
this early age intestinal affections were little or not at all discovered. 
The examination of a girl of fifteen years, who died after the fourth 
week of the disease, resulted in the following facts : Meninges and 
brain contained a moderate amount of blood, the ventricles little se- 
rum. Lungs were full of blood, otherwise normal ; in the heart, 
black and fibrinous coagulations were found ; the liver was normal, 
the spleen very much enlarged, seventeen centim. long, eight broad, 
and three and a half thick ; it was soft and dark ; kidneys and mu- 
cous membrane of the stomach normal ; mesenteric glands some- 
what swelled ; the small intestines were nowhere ulcerated, Peyer's 
glands slightly swelled, some small sugillations near the ccecum ; 
solitary glands normal. The mucous membrane of the large in- 
testines were nowhere softened nor swelled, but generally very hy- 
peremia Another child, feeble and emaciated, left no pathological 
signs. A third patient, already recovering, was affected with peri- 
tonitis of the right side, and died twelve days afterwards. The fun- 
dus of the gall-bladder was perforated and surrounded with a puru- 
lent peritoneal exudation. In the dilated gall bladder there were 
some ulcers of diphtheritic appearance, ductus choledochus was ob- 
literated probably in consequence of ulcerous inflammation of the 
dilated gall-bladder. In general, the results of Prof. Lebert agree 
with those of Dr. Friedrich, who has proved alterations of the intes- 
tines and pathological changes in general, to be by no means frequent 
in abdominal typhus of the infantile age. Besides, it is well known, 
that Drs. Rilliet and Barthez have found resolution of the swelled 
glands of Peyer to be not an uncommon process even in a stage of 
the disease where ulceration is going on actively. 

The subject of Dr. Bazin's book has been treated of so many times 
and so variously, that the reader will necessarily expect some new 
facts or views in opening another volume on the same subject. We 
must confess that he will feel sadly disappointed. The author's dis- 
coveries are no discoveries, his new facts are very old, his classifica- 
tion is either prolix or confused, and his pathological views are very 
antique indeed. The old doctrine of diatheses is confessedly only a 
scape-goat of our ignorance, so much so, that every educated physi- 
cian of the present time feels somewhat confused or unsatisfied in 



330 

merely pronouncing the word ; the author, however, is so far from 
feeling the necessity of limiting the use of the term of " diathesis," 
that he invents some other diatheses besides those the unsatisfactory 
state of modern pathology requires. According to him, a diathesis 
is " an acute or chronic, feverish or unfeverish, continued or inter- 
mittent, contagious or not contagious disease, characterized by the 
formation of one, single, morbid product, which may have its seat 
indiscriminately in all the organic systems." Thus there are purulent, 
chondromatous, tuberculous, hemorrhagic, serous, saccharine, and cal- 
culous, pseudo-membranous, gangrenous, adipose, fibrous, cancerous 
diatheses (p. 10). Nothing can be more convenient than to hide one's 
self behind the screen of a Greek word with more sound in it than in- 
telligibility and pathological signification. One of the "discoveries" 
of the author is that the lesions of the skin are no diseases, but symp- 
toms of diseases ; that, therefore, the investigation of cutaneous 
eruptions ought to be considered as a part of general semiotics. 
Another discovery of the author's is, that cutaneous diseases are 
affected either by external or by internal causes, and that parasitical 
diseases belong to the first class ; that parasitical diseases have 
been confounded with cutaneous affections from internal causes up to 
his, the doctor Bazin's time, but that, "God be praised fqr it," this 
family is now at last established on a solid basis. As his third im- 
portant discovery the doctor asserts, that cutaneous eruptions from 
internal causes are "either congenital or pathological." Nsevi and 
ichthyosis belong to the "congenital" affections, the "pathological" 
are composed of the exanthems, and the whole number of diseases of 
the skin called impetigines by Frank. The usual name of these " im- 
petigines " is tetter, according to the author ; for which four princi- 
pal diatheses can be found to exist, viz., scrofula, syphilis, herpetism, 
and arthritis. Now tetter, when the consequence of only one dia- 
thesis, is very easy to diagnosticate and to cure ; but it is often 
the result of a - number of diatheses combined, and then our author 
declares it to be truly a terrible affair. Thus our readers perceive, 
that the author not only turns his back upon even a trial of physiolo- 
gical investigation, but hastens to return to the very worst ontolo- 
gical period which medical science has long ago overcome. This 
book is a useless play-work of classifications and sub-classifications, 
without scientific foundation, without new facts. The only thing new, 
is his return to ontology ; his manner of writing and explaining is 
very discouraging. We venture to pronounce the opinion, that 
nobody will ever read this book from the first to the last page, 
except the author, without becoming either simply tired or thor- 
oughly disgusted. 

Dr. Peloly defends Piorry's opinion on the absence of a peculiar 
diathesis in what is generally known by the collective name of scro- 
fulous affections. We may say that the opinions of medical men of 
modern times on this subject, are not very different from each other, 
although they may appear to be so ; for it is evident, that a local 
trouble affecting digestion and assimilation, will always influence 
the formation and composition of blood, and that very often what 
was but the consequence of a local affection, has been mistaken for 



331 

the original cause of later troubles of the system. From this point 
of view we regard the seeming difference between the opinions of 
Prof. Von Dttben and Faye. We think that both of them will readily 
subscribe to the following notice on Mr. Duriau's report on Prof. Pi- 
orry's lecture on scrofula,* published by us in the N. Y. Jour, of Med., 
Nov., 1858 : 

" Inflammatory action becomes manifest by the stopping of san- 
guineous or lymphatic circulation, by the coagulation of the liquid 
contained in the vessels, and, finally, by the exudation of a plastic 
lymph. After the inflammation has ceased, circulation may take 
place again by means of the vessels, but the plastic product exuded 
into the interstitial cellular tissue will not disappear in the same 
manner. It will undergo a process of condensation, and leave an in- 
duration of the ganglion, which by itself will, more or less, prevent 
lymphatic circulation, and give rise to a new pathological affection 
somewhere else in the organism. Thus, such an induration must not 
be considered as the symptom of a specific diathesis. Now, these 
indurations are very slow in their development, and especially does 
suppuration take a very slow and tedious course. But this, although 
being a general fact with "scrofulous " individuals, is not a proof of 
the existence of a peculiar diathesis ; for all such patients, suffering 
from the influence generally admitted to be the cause of l ' scrofula," 
as inappropriate food, bad air, etc., have a small heart, a small quan- 
tity of blood, and exhibit a slow circulation ; and undoubtedly, ac- 
cording to Magendie, the circulation of the blood has a direct influ- 
ence on lymphatic circulation. Therefore, in cases of this description, 
reaction and absorption are less powerful. " Scrofula," then, is but 
a defective development of organization, with the characters of anae- 
mia or hydrsemia, and consequently a disposition to indurations and 
swellings of the ganglia. Moreover, Lebert was unable to detect 
hereditariness of "scrofulous" symptoms in more than a third of his 
cases — an assertion which diminishes a great deal the necessity, of 
assuming a diathetic peculiarity. Neither the general disposition, 
nor real local lesions must be classified as a specific disease. Even 
the chemical alterations of the blood, that have been found, are to be 
considered as a consequence of local lesions and the general quality 
of the blood, and not as a primary disease. Scrofula, then, is no 
more a specific disease according to Piorry than according to Vel- 
peau." 

Of the book of Dr. Masse" on epilepsy, tetter, and scrofula, the fourth 
edition has appeared. It is destined to enlighten the public on the 
nature and cure of those obstinate diseases, and to prove, what 
nobody ever denied, that not all the cases of epilepsy, tetter, or 
scrofula are incurable. 

Dr. Hauner, in all scrofulous affections, attended always to the 
general disease ; taking scrofula to be always the consequence of 
vicious alimentation. He never saw a local cure yielding successful 
results. As to special and specific medicaments, he declares to have 

* De la scrofule, le$ons cliniques, professdes a 1' Hopital de la Charity. Par M. 
Piorry, recueillies par M. Frederic Dcriau, Paris, 1857. 



332 

never seen any effect of cod liver oil on scrofula and tuberculosis of 
children ; but highly praises the administration of equal parts of 
old claret and Heilbronn water, from four to eight teaspoonfuls a 
day. 

Dr. Leriche puts his confidence in iodine. His method of adminis- 
tering it, is to give a syrup of the seeds of sisymbrium officinale with 
iodine. Besides, he likes to prescribe tincture of iodine to be taken 
in claret. We should always prefer to administer a medicament in 
a simpler manner, and do not think that a practitioner will find it 
very difficult in private practice to cure, without Dr. Leriche's 
recipes, 21 scrofulous patients out of 38, in the course of several 
years. One case of cured scrofula has been reported by Dr. Lebert, 
who refers to a young man of sixteen years, who had been suffering 
from scrofula for six years past, and did not get well before having 
had, for a while, his bread mixed with iodine. 

Dr. Engert gives a report on the cases of scrofula and tuberculosis 
observed during the course of a year, in the Children's Hospital of 
Munich. He counts such cases of scrofula only, where the diagnosis 
cannot be doubted because of preceding diseases, hereditary in- 
fluences, and evident scrofulous habitus. Rhachitis, craniotabes, 
idiotism, and struma are not counted in the number. Of 2,916 patients, 
360 were scrofulous. In f0 others suffering from diseases of the 
eyes and skin, the origin was dubious. There was no difference as to 
sex, 178 boys, and 182 girls being affected. The majority of cases 
occurred from the second to the eighth year of life ; 10 per cent, of 
the whole number of cases belonging to the second, 28 per cent, to 
the eighth year. The relative immunity from this class of diseases, 
in the first period of life, Engert explains by the prevalence of in- 
testinal diseases followed by atrophy and death, before constitutional 
diseases have a chance to finish their slow course. Scrofula in the 
360 cases referred to, showed itself in 10 per cent, as tubercular dis- 
ease, in 20 as diseases of bones and joints, in 40 as ophthalmic dis- 
eases, in 22 as cutaneous, and in 8 per cent, as affections of the mucous 
membranes. Hereditary influence appeared to act most unfavorably, 
as cause of the* disease ; so did moisture and darkness of the rooms ; 
food seemed to be of less dangerous influence. The treatment was 
more a dietetic one, than by medicaments ; as iodine, the syrup of 
the iodide of iron, and cod liver oil containing iodine. 

Dr. Hutchinson records the case of a boy who exhibited the first 
swelling of a testicle when a year and five months old. At the age 
of 2 years 3 months the testicle was operated upon and a medullary 
cancer of the size of a man's fist removed. The child was well for 
8 months, when symptoms of pulmonary cancer developed them- 
selves. He died eleven months after the operation had been per- 
formed. Both of the lungs were infiltrated with medulary cancer. A 
cancer of the size of a pea was found in the liver, but nowhere in 
the other abdominal organs. Two aunts of the patient, sisters of 
his father, had died from cancer of the mamma. 

Dr. Diday again, as in his "Essay on Syphilis of New-born Infants 
and Nurslings" (Paris, 1854, pp. 439), discusses the important ques- 
tions : by whom the infant can become infected, and whom it can 



333 

itself infect. The infant may be infected by the father, although he 
does not show actual symptoms of syphilis ; it may be infected by 
the mother either in the moment of conception or during pregnancy ; 
•it may be infected by its nurse. Again, the foetus after having con- 
tracted syphilis from the father, can infect the mother ; and the in- 
fant suffering from hereditary syphilis can give the disease to any 
body that approaches it, because the lesions of hereditary syphilis, 
although showing the outside appearance and evolution of secondary 
syphilis, are distinguished from common syphilis by their being as 
contagious as primary accidents. The elucidation of these facts, 
which begin gradually to be taken as such by the whole profession, 
we principally owe to Dr. Diday. 

Dr. De Meric considers hereditary syphilis from two points of view — 

1, the limitation of time as to the appearance of the symptoms ; and 

2, the action of the infected foetus upon the healthy mother. Out of 
forty-six cases of hereditary syphilis in children born alive, only two 
presented at birth distinct symptoms of syphilis ; two a few hours 
after birth, four a few days, five from ten to three weeks, ten from 
six to thirteen weeks after birth. Thus there were 21 cases in which 
the symptoms appeared before the child was thirteen weeks old. In 
seven other cases the symptoms appeared at the age of three months, 
fourteen months, twenty-one months ; two years and three months, 
eight years, twelve years, fifteen years. As to scrofulous diseases 
being the consequences of hereditary syphilis, Dr. De Meric doe»not 
feel entirely satisfied, nor does he allow of more than the possibility 
sometimes proved, sometimes denied by facts, that the mother may 
be infected by the syphilitic foetus. 

The main points of a lecture delivered by Dr. Parker, are the fol- 
lowing : A father having symptoms of constitutional syphilis at the 
time of marriage, or at periods more or less remote before it, may 
procreate a diseased infant, and the mother may never exhibit any 
symptoms of disease. The explanation of these cases appears to be, 
that the ovulum is impregnated with diseased semen, and its product 
is consequently diseased. The chances are in favor of the child 
escaping, if the outbreak of disease has been very violent, i. e., if the 
skin has been loaded with eruption, or again, if the patient has 
been submitted to a prolonged and energetic treatment. The mother 
sometimes retains ,her immunity, but in a number of cases does not ; 
in such cases, the mother derives her disease from the foetus, a proof 
whereof is the fact, that the symptoms of syphilis in the mother very 
frequently disappear after abortion or delivery, even without treat- 
ment. Some even assert the mother to get diseased sometimes from 
the seminal fluid alone. The mother may be the source of disease to 
her foetus,, or infant, in four ways : 1, she may be diseased before 
conception ; 2, she may become diseased after she has conceived ; 3, 
she may disease her infant in its passage through the vagina, or 4, 
after birth. Where the father impregnates the foetus with diseased 
semen, the infant, having been developed in the womb of a healthy 
female, will usually be cured ; a cure is probable also in an infant, 
whose parents were both healthy before its birth, but whose mother 
was diseased afterwards, and communicated the disease to her 



334 

offspring. Where the infant is conceived and developed in the womb 
of a mother diseased before conception, the prognosis is most un- 
favorable. 

Dr. Knoblauch reports a case of hereditary syphilis occurring in a 
girl of two months, who, at and after the age of six weeks, was 
affected with syphilitic coryza, spots and pustules rapidly trans- 
forming into ulcers. The copper color of syphilitic eruptions is not 
always found, not even in adults ; in children, seldom anything else 
is observed except the usual redness of congestion and inflammation. 
Dr. K. cured his patient, by the use of calomel, within forty days. 

Dr. White reports a case, in which parents, being syphilitic about 
the time of their marriage, had 5 children in 6 years, all of whom 
were syphilitic. 

Drs. Friedinger, Mayr, and Zeissl consider the principal forms of 
syphilitic eruptions in infantile age to manifest themselves as — 1, 
maculated or squamous ; 2, papulous ; and 3, pustulous. The macu- 
lated form is usually found in the face, and consists rather of a decolor- 
ation of the flabby and dry skin, than of a real eruption. The skin, 
although very dry, looks rather fatty, particularly after the spots 
have turned either intensively pale or brownish, and spread over 
chin, cheeks, forehead, and, at a somewhat later period, over nates 
and extremities. The spots, by their not disappearing when pressed 
under the finger, proved to be of pigmentous nature. Sometimes 
spots are found either on the maculated brownish surface or on the 
hitherto healthy skin, which can be compared to roseola only ; they 
seldom remain unaltered, but in the majority of cases rapidly change 
into psoriasis, flat condylomes, or tubercles, or ulceration. The papu- 
lous form is rarely independent of complications, but usually com- 
bined with the maculated form ; it is usually brownish, and consists 
of small knots, either dispersed or in groups, mostly on the volar sides 
of feet and hands ; it undergoes either inflammation (acne) or suppu- 
ration. Dr. Friedinger observed a case, where but the inferior half 
of the body was affected with this eruption ; the efflorescences were 
distinctly separated from each other, but gradually enlarged so much 
as to form uneven, infiltrated spots, but little elevated above the sur- 
face of the healthy skin. The dry exudation turned into a thin scurf, 
leaving the corium dry, and not bleeding like the corium in syphilitic 
psoriasis. The pustulous form is, in Dr. Zeissl's opinion, less frequent 
in newly-born infants than in adults ; in none of his cases the mother 
was proved to have been syphilitic — in every one the father. This 
form is either developed in utero (such infants will die before birth 
or in the first eight or ten days of life), or within eight days after 
birth ; in such cases the little patients lived from twenty to twenty- 
two days. The opinion of Cazenave and Dubois, who believe puru- 
lent vesicles to be found on the volar sides of feet and hands, Dr. 
Zeissl declares to be erroneous. Nor does this observer agree with 
Cazenave's assertion, that ulcers will always follow the rupture of 
purulent vesicles, Dr. Zeissl considering desiccation and peeling off of 
the epidermis as a much more common occurrence ; this being the 
more certain, the less strength and embonpoint is left to the patient. 
Loss of substance is perceived only on the sacrum and calcanous, 



335 

where rhagades are found partly from infiltration of the cutis, 'partly 
from supination. 

Dr. Thiry reports the case of a still-born child, showing the 
anomaly of the liver, which is considered by Gubler as characteristic 
of syphilis. The liver was enlarged, hypersemic, and contained 
numerous oval, whitish-yellow nuclei, of different sizes and fibro- 
cartilaginous hardness. The tissue consists of cells, more or less 
elongated, without nerves nor vessels, that is to say, of fibro-plastic 
tissue in the first period of development. The parents had not been 
closely examined for syphilis, but the mother had undergone three 
successive abortions before. Thiry considers the main characteristic 
of this hepatic disorganization to consist in induration ; the fibro- 
plastic production, although observed in every form of constitutional 
syphilis, differing only according to the variety of organs and tissues. 

From a number of cases Mb. Hutchinson draws the conclusion, 
that the period of the first dentition in infants affected with heredita- 
ry syphilis seems to be accelerated. In cases where information 
could be obtained, 2 had their teeth at birth, 1 when a few weeks 
old, 2 about two months after birth, 2 about the usual time ; the re- 
mainder very late. The teeth are generally small ; although the 
alveolar arches are decidedly below the average, size, there are in 
most considerable spaces between the teeth ; they are more round 
in form, resembling little pegs ; they are often worn from mastica- 
tion, the enamel being very soft. In nearly every case there is a 
deficiency in the superior alveolar arch, at the anterior portion, so 
great in some patients, that the upper and lower incisors are a con- 
siderable distance from each other when the mouth is shut. The 
color of the teeth is of a dirty translucent shade. 

The same author reports a death from hereditary syphilis after 
a month's illness, with disease of the heart. The pericardium was 
distended with coagulated blood, the source of which was not ascer- 
tained. The father and mother had primary syphilis two months 
before the birth of the child. 

Dr. Friedinger reports a case of hereditary syphilis, which was due 
to the father only, the mother having never been affected by syphilis 
neither before nor during pregnancy. Vaccination in the syphilitic 
child proved successful, no anomaly being exhibited in the develop- 
ment of the pustules. The use of vaccine matter taken from the 
child affected with latent syphilis, proved entirely unable to produce 
any inconvenience in the vaccinated children . A successful cure of 
hereditary syphilis can be effected by means of mercury, but not 
without the child being nourished by breast-milk. 

Syphilization has been resorted to in hereditary syphilis first by 
Prof. Boeck, of Cbristiania, afterwards by Prof. Sperino. The ma- 
jority of cases exhibited the papulous form. The more imminent the 
danger appears to be from this grave disease, the more highly this 
method of treatment, in Prof. Sperino's opinion, is indicated. 

Dr. Godfrey reports four cases of diphtherite, and believes the order, 
in which its symptoms generally occur, to be this : Shivering ; in- 
tense depression ; dryness and tingling of the throat, nares and 
ears ; external swelling of the glands ; a whitish §pot on the 



336 

mucous membrane of the tonsil, gradual deepening in color as the 
disease progresses ; dysphagia and dyspnoea ; dilated pupil ; im- 
pending asphyxia, and death. The disease appears to Dr. God- 
frey to be confined to the mucous membrane, neither touching the 
muscular nor grandular structure. The glandular enlargement is 
due to sympathetic irritation. Its diagnostic difference from scarlet 
fever consists in : 1. The abscence of all fever ; 2. absence of all 
rash ; 3. papillae of the tongue not enlarged ; 4. no desquamation 
of the cuticle after the disease passes off. In cynanche tonsillaris 
the abscess forms within the tonsil, and bursts its way out, but in 
diphtherite, the morbid change qommences on the surface of the mu- 
cous membrane, and is confined solely to that covering. The ex- 
treme and rapid depression is only equalled by the depression of ma- 
lignant scarlet fever, or the collapse of Asiatic Cholera. Each patient 
that died appeared to sink from exhaustion and partial asphyxia. The 
main point in the treatment is to support the patient's powers, by 
stimulants and tonics ; and to check the inroad of the disease by the 
application of the strong mineral acids. Tracheotomy is unsafe, be- 
cause the depression of the patient's powers is far greater than the 
dyspnoea, and the depression, while appearing before the dyspnoea, 
cannot result from the blood being improperly aerated. Dilatation 
of the pupils existed as a marked symptom in every case. Dr. God- 
frey believes the tincture of sesquichloride of iron the best remedy. 

A large number of notices on diphtheritis contained in the Eng- 
lish journals, are not deserving of any particular attention. The 
disease being unknown in England, the practitioners of that coun- 
ty think every trifle known everywhere except in England, worthy 
of being printed. Amongst them are the specimen of "the tonsils 
and other parts from a case of diphtherite," exhibited by Dr. Ogier 
Ward in the Pathological Society of London ; the discussions in the 
Harveian Society of London as reported in the Lancet, which never 
led to a result, each of the members expressing his opinion and 
keeping it, and no unanimity as to its local or general character 
being arrived at ; the cases recorded by Dr. Godfrey ; those of Dr. 
Fuller and Dr. Greenhow, and the two cases reported by Mr. Browne, 
of deaths by diphtheritic dissolution of the blood, which he re- 
gards as a new disease, though allied in some of its character to 
malignant " scarletfever." Rapid deaths by diphtheritis seem to be 
of a very rare occurrence in Great Britain, which is an interesting fact 
as to nosography. Thus, after all, an English physician may be 
excused for never having seen the disease in question, but not for the 
total want of knowledge of its existence. For there is scarcely a 
manual on the diseases of children on the continents of Europe and 
America, and in England too, that would not state the fact, that 
some cases of diphtheritis faucium have such an asthenic, adynamic 
type, and accompany such a general depression of every vital 
function as to cause death in a short time, without apnoea or any 
visible material change in the organic structure of the body, except 
the diphtheritic exudation on the fauces. Such cases are to be con- 
sidered as proofs of a rapid dissolution of the blood, similar in its 
effect to the typhous. The like want of knowledge of their own 



337 

and foreign literature has been shown by the Medical Society of 
London, where Dr. Camps read a paper on the same subject. 

The only continental work known to the English writers appears 
to be Bretonneau, Des Inflammations Spe'ciales du Tissu Muqueux, et 
en Particulier de la Diphthdrite, Paris, 1826, while the Manuals of 
Verson, Rilliet and Barthez, Bouchut, Bednar, Hennig, Schnitzer and 
Wolf, Goley, West, Churchill, Evanson and Maunsell, even Under- 
wood, Condie, Meigs, etc., may be found to contain many remarks on 
the same subject. Even a good paper written by Dr. Hamilton, for 
Ed. Med. Jour., Vol. II., p. 235, is unknown to his own countrymen. 

Mr. Henderson states, that diphthertic affections, after having been 
quite unknown in Aberdeenshire, have assumed the form of an epi- 
demic. The history of his case corresponds with what is generally 
known of diphtheritis. Tracheotomy was performed, but proved un- 
successful, as is generally the case in true diphtheritic affections with 
a thorough decomposition of the blood. At all events, by means of 
the operation, " life was prolonged, and suffering was arrested." 

According to Dr. Farr's report, diphtheria proved very fatal in 
Norfolk, Suffolk, Essex, and Staffordshire. Four hundred cases have 
been attended at Bradwell, in Essex, where eight died out of twenty- 
one. "Diphtheria is," in Dr. Farr's opinion, "like Asiatic cholera, 
probably a more intense form of an old disease." 

Mr. Camps draws the following conclusions from the facts he col- 
lected : 1. A disease very analogous to, if not identical with that 
described by Bretonneau as diphtherite, had existed in England for 
some years. 2. This disease was mainly of an asthenic, adynamic 
type ; and characterized in the severer cases by the formation of 
plastic pseudo-membranous exudations. 3. It was primarily pharyn- 
geal as to its seat, and not laryngeal, ergo secondarily, and by com- 
plication ; thus -differing anatomically from croup. 4. Its difference 
from stomatitis was a difference of degree or intensity, rather than 
a difference of kind ; and one chief point of difference from the ma- 
lignant sore throat, consequent upon scarlatina, consisted in the ten- 
dency to the formation of plastic pseudo-membranous exudations. 
5. In many instances this disease possessed the characters of an epi- 
demic. 6. The treatment should be both topical and general ; the 
topical consisting of applications of nitrate of silver, or chlorine, or 
hydrochloric acid ; the general comprising the administration of 
chlorate of potassa, with chlorine, or a combination of cinchona bark; 
or its alkaloids ; and in the severer cases, calomel in repeated doses, 
so as to produce ptyalism. In the early stages emetics have proved 
useful. The vital powers must be well sustained by wine, stout, 
beef tea, and other -invigorating means. 

The Registrar-General, while reporting on the existence of epidemic 
diphtheria in France, avails himself of the occasion to urge the im- 
portance of fresh air, and especially the removal of the sewer gases 
into the atmosphere in a direct manner, through pipes running up, 
and at least as high as the chimneys. 

Mr. Heslop recommends, in diphtheria, the administration to an 
adult, of about twenty-five minims of the London tincture of sesqui- 
chloride of iron every two, three, or four hours, conjoined with a few 
22 



338 

drops of dilute hydrochloric acid. He also applies daily, sometimes 
twice a day, by means of sponges, a solution of hydrochloric acid, 
and always enjoins the regular use of weaker gargles of the same 
acid. Stimulants, beef-tea, milk, jellies, constitute the dietetic part 
of the treatment. 

The discussion of the Albany County Medical Society resulted in 
recommending emetics, to cleanse the stomach and fauces of vitiated 
secretions, gargles of diluted vinegar, and the mineral acids and 
tonics very early in the disease to counteract the tendency to the 
typhoid condition. Chlorates of potassa and soda were only men- 
tioned in reference to their use as gargles ; their internal use was not 
discussed. 

In Mr. Fourgeaud's opinion, diphtheritis is merely a local affection. 
He is opposed, therefore, to Mr. Blake, who considers, with the ma- 
jority of modern writers, the main thing to be the diphtheritic fever, 
and all the sometimes severe and sudden symptoms pointing to dis- 
solution of the blood. If diphtheritis was -only a local process, the 
accompanying fever, the general debility, and miasmatic expansion, 
could not be well explained. Fourgeaud's opinion in this re- 
spect, as well as his therapeutical treatment show him to be well ac- 
quainted with the older literature, but entirely ignorant of the results 
of late years. While fully agreeing with his expositions on the 
application of muriatic acid and nitrate of silver, while further fully 
admitting the danger of performing tracheotomy in secondary 
croup, we entirely disagree on the antiphlogistic, local and general, 
treatment recommended by the author ; for we have no doubt, that 
the general debility and dissolution of the blood will not be pre- 
vented or cured by antiphlogistics and purgatives, and that local 
bleeding in cases of tumefaction of the throat, and the submaxillary 
glands, will do good in only very few cases. A tonic, restaurant, 
stimulant general treatment (together with the almost specific anti- 
diphtheritic remedy, chlorate of potassa), and stimulant embroca- 
tions to the neck, have proved more useful and appropriate. The 
author not being acquainted with the use of chlorate of potassa 
proves by this very fact, that he is not acquainted with the results 
of scientific researches and experiments of the last three or four 
years. 

Mr. Thompson is inclined to adhere to the opinion, that diphtherite 
may be a modification of scarlet fever. " The following are the rea- 
sons for considering so : 1. Diphtherite prevailed in this neighbor- 
hood as a contagious epidemic at the same time as well marked scar- 
let fever, and chiefly among children. 2. In the same house the 
father and mother had well marked scarlet fever severely, without 
any ulceration or deposit on the throat ; while the three children had 
all the marked symptoms of diphtherite, without •much feverishness 
and no rash, though attended by the same premonitory symptoms ; 
the cases occurring at the same time. 3. In many instances, cases 
of apparently pure diphtherite were, after some days, attended by a 
rash, that seldom remained more than a few hours. 4. The disease 
in most instances commenced with all the symptoms of fever, its du- 
ration being similar to that of scarlet. 5. In cases of apparently 



339 

pure scarlet fever, the throat became, after a few days, covered with 
a diphtheritic deposit. 6. The sequelae of the two diseases nearly 
resembled each other. Albuminous urine, with casts, being present 
in eight cases of diphtherite ; and anasarca proving fatal from con- 
vulsions in one." 

Dr. Semple is much opposed to the assumption of an identity of scar- 
let fever and diphtheritis. The onset in the cases he observed, was 
very insidious ; the diphtheritic membrane had often reached the air- 
passages before advice was sought. Death ensued from asphyxia, 
but in many more cases from exhaustion. 

The principal fact Mr. Wade lays stress upon, is the presence of 
albumen in the urine as a common symptom ; then he goes to show 
that neither the false membrane, nor the fatal croup, ought to have 
induced Bretonneau to consider diphtheritis a new disease, and 
pathologically different from scarlatina. As to the initial fever, he 
rightly observes, that the stage of reaction bears no relation in in- 
tensity to the stage of depression (or rigors) ; that the initial fever, 
though frequently slight, bears no relation whatever to the amount 
or extent of the exudation on the fauces. Sometimes Mr. Wade has 
found a certain diminution of the general symptoms, with the first 
appearance of the exudation. Mycelium and O'idium albicans, as 
found in the exudate membrane, by Dr. Laycock and Mr. Jauncey, 
he did not find ; but in one case he saw the leptothrix, which, how- 
ever, is common in various forms of disease. As to albuminuria in 
diphtheritis, the author thinks too much of its importance and dan- 
gerousness ; it being indeed a very common symptom in the first 
stage of diphtheritis. Mr. Mangin has proved, moreover, that albu- 
minuria, wherever found, accompanies the first stage of diphtheritis, 
while in scarlet fever, it is seen with or after desquamation. Be- 
sides, according to his experience, albumen is found in almost all 
the cases of diphtheritis, and always in large quantities, while it is 
not seen in the majority of cases of scarlatina, and never in a large 
quantity. Cutaneous eruptions may be found from several causes. 
Either they take their origin from a former disposition, or are like 
the erythems observed in cases of virulent or miasmatic poisoning, 
or the skin is simply congested by the general fever. Such erup- 
tions, then, in Mr. Mangin's opinion, are never peculiar symptoms of 
diphtheritis. 

Dr. Laycock compares diphtheria and muguet, and endeavors to 
show that either of these diseases is due to the presence of a para- 
sitic fungus on the surface of the mouth, fauces, and other mucous 
structures. The sporules and mycelium of the oldium albicans, 
which are, besides in diphtheria, found also in muguet, act as an irri- 
tant, inducing increased formation of epithelial scales and effusion 
of mucous exudation corpuscles, or plasma ; intermingled with 
these, are the sporules, and the mycelium of the microscopic fungus ; 
the whole constituting a pellicle. This .fungus, however, appears 
not to be limited to one form of disease. Dr. Laycock has had a 
case of syphilitic disease of the fauces and pharynx, in which the 
pellicle containing the o'idium was noted, and which seems to have 
introduced it into the clinical wards. Whenever there is an epi- 



340 

demic of scarlatina, the presence or absence of the fungus, in each 
individual case, will decide on its character, whether diphtheritic or 
not. The condition of the intestinal and bronchal mucous membranes 
seem to be not very favorable to the formation of the mycelium, or a 
pellicle ; still inflammation, and even ulceration of these surfaces, 
will occur as the result of the irritative action of the parasite. In 
diphtheritic croup there is no mycelium, either because the weather 
is cooler when it prevails, or because the mucous membrane of the 
larynx and trachea, being cooler generally, from the transit of air, is 
less favorable to the development of the mycelium. The fungus, 
however, may fix upon any suitable portion of the skin, thigh, labia, 
malleoli, and angles of the eyes and mouth. The diagnosis from 
ordinary aphtha is not difficult ; this latter disease is vesicular, and 
the white specks or patches are ulcers, while in diphtheria they are 
pellicular, and not ulcerous. The redness, too, is much deeper in 
diphtheria, and there is no o'idium in aphtha. The indications in the 
treatment are given by the constitutional condition, which is always 
low and asthenic tonics, stimulants, antiseptics ; and by the local 
affections, in which the remedies called parasiticides are the best ; 
biborate of soda, chlorate of potassa, bichloride of mercury, any 
metallic salt ; particularly perhaps, chlorides, alkaline gargles and 
applications, nitrate of silver. Diphtheria, as due to the oldium 
albicans, is infectious and contagious. 

Mr. Wilks endeavors to show that a vegetable fungus may spring 
up on the buccal mucous surface in various cases of diseases, but 
requiring, probably, some previously morbid condition for a nidus ; 
but that. the pellicle in diptheria is ahcays composed of a vegetable 
parasitic fungus. • 

The result of Dr. Hauner's observations on diphtheritis are laid 
down in the following, viz.: Diphtherite generally, and diphtheritic 
angina and laryngitis particularly, are originally observed in feeble 
children and such as have been suffering from preceding (mostly ex- 
anthematic) diseases. It is contagious and infectious ; may kill 
either by intoxication, or exhaustion, or secondary affection of the 
larynx, trachea, or bronchi ; and will never be cured by antiphlogis- 
tic treatment, but only by roborants and local treatment. Dr. Hauner 
applied in all his cases the solid caustic to the tonsils and fauces, 
sometimes using a strong solution of it, and always sufficiently to 
form a line of demarcation between the diseased and the healthy 
parts. The internal treatment consisted of chlorate of potassa, 3ss. 
or i. daily, quinine, and a roborant diet. Aromatic baths proved 
useful. 

Mr. Kingsford publishes a very judicious essay on diphtheria, divi- 
ding it into a mild form, viz., diphtheritic sore-throat, and a severe 
one, viz., genuine diphtheria. This latter is highly dangerous. No 
antiphlogistic remedies must be adopted ; it should be borne in mind 
that the fever is the result of a poison analogous in type to adynamic 
erysipelas. The pharynx Should be sponged every 8 hours with a 
solution of lunar caustic • a most liberal allowance of wine and 
nutritious diet must be instituted from the first, and the following 
draught : chlorate of potassa, 10-30 grains ; tinct. of sesquichloride 



341 

of iron, 10-30 minims ; syrup, 1 drachm ; water, 7 drachms ; given 
every one, two, or three hours. The more intense the inflammatory 
symptoms, the oftener should the draught be administered ; nourish- 
ment also should be given in intervals. Cases in which deglutition 
is impossible, or voluntary efforts at swallowing are resisted, require 
clysters of beef tea and port wine every two hours in older children, 
combined with quinine. At the same time the topical application of 
the nitrate of silver must be persevered in ; no mercury must be 
given except as a cathartic at the onset of the disease ; no blistering 
and external stimulants applied, they being worse than useless. 
Tracheotomy, if entertained, should be entertained immediately after 
the croupous symptoms have become established, and not deferred as 
a dernier ressort ; the author does not say whether he ever saw a suc- 
cessful case of tracheotomy in diphtheria. "When the affection of the 
throat assumes the malignant or putrid type, a gargle ought to be add- 
ed, consisting of one drachm of liquor chloride of lime and 8 ounces 
of water. A very serious complication, in severe forms of diphtheria, 
is paralysis of the muscles of the neck, of the pharynx, and of the 
larynx ; such cases require change of air, and those remedies which 
are calculated to improve the general health ; the nervine tonics are 
especially indicated. 

Prof. Bouchut, of Paris, has done to his utmost during the year to un- 
dermine what reputation he has obtained by former labors. In his 
opinion the false membranes will be best removed by emetics, or by 
cauteries, of which he would prefer the hydrochloric acid to nitric 
acid, nitrate of silver to the actual cautery. He generally applies 
glycerine, which is expected by him to dissolve false membranes, 
when not too hard. Of internal remedies he is, rightly, afraid of 
mercury ; but he sins as much as those who recommend mercury, by 
praising divided doses of antimony. Of chlorate of potassa, he 
declares to have seen no effect whatever. So far, all may be right ; 
but, finally, he goes as far as to praise the excision of the tonsils as 
an infallible remedy in cases of diphtheritic membranes. 

Dr. Baron recommends carbonate of soda or the Vichy waters. 

A case of hydrophobia observed by Prof. Santesson, of Stockholm, 
occurred in a girl eight and a half years old. The disease showed 
itself on the forty-fifth day after the child had been bitten, and 
resulted in death after two days' intense suffering. Postmortem ex- 
amination eighteen hours later : considerable rigor in the maxillar 
joints, the joints of the lower and particularly the upper extremities 
being somewhat more flexible. When the external integuments were 
being incised, there was a smell of chloroform, which the child had 
inhaled before death. The inner side of the galea, corresponding 
with the spot where the child was bitten, had its blood-vessels pretty 
much injected with blood ; also the cranium was, in the correspond- 
ing part, somewhat exfoliated. The cerebral membranes were nor- 
mal, the venous vessels of the arachnoide, particularly on the basis, 
abnormally filled with blood. The cerebral substance was normal, a 
little hyperaamic ; the lateral ventricles contained some clear serum; 
the choroid plexus of the right lateral ventricle was somewhat 
extended by serum. When the thorax was being opened, the lungs 



342 

did not collapse ; after an incision was made, a large quantity of 
dark fluid blood effused , the right lung adhered to the thoracical 
pleura by old adhesions ; its middle lobe was almost entirely col- 
lapsed ; the bronchia, in this part, were dilated and filled up with a 
purulent liquid. On the outside of one of them was a calcareous con- 
crement of the size of one half of a pea. The mucous membrane of 
the larynx was pale, of the trachea red, and everywhere below the 
bifurcation, in all the bronchia, highly congested. The left lung 
showed interlobular emphysema. The heart was normal and con- 
tained liquid blood and fibrinous coagulations. The mucous mem- 
brane of the fauces was not particularly injected ; the tonsils were 
swollen ; when incised, a purulent fluid escaped. The superior sur- 
face of the tongue was pale and covered with some mucus ; the 
inferior surface showed no blisters of any kind or size. There were 
some erosions on the mucous membrane of the stomach, particularly 
near the pylorus. The intestines and spleen were normal, liver and 
kidneys normal, but hyperaemic. 



III. ORGANS OF DIGESTION. 

1. Neudbrfer, Contribution to the Operation of Hare-Lip. — Oest. Z. f. 
prakt. Heilk. 32. 

2. Duke, Allen, New Operation for Hare-Lip. — Lancet. Feb. — N. Y. 
Jour, of Med. July. 

3. Guersant, on Hare-Lip Operations. — Gaz. d. Hop. Nov. 24. — Med.- 
Chir. Rev. July. 

4. Volkmann, Case of Sudden Death after an Operation of Hare-Lip. 
Monatschr. f. Geb. May. — N. Y. Jour, of Med. July. 

5. Tamele, J., on Split Palate.— AUg. Wien. Med. Z. 45. 

6. Butcher, on the Proceedings Employed in the Operation of Hare- 
Lip. — Jour, de Med. Chir. Pharm. 

7. Morrogh, Case of Congenital Hypertrophy of the Tongue, and Am- 
putation. — Med. and Surg. Rep. Jan. — N. Y. Jour, of Med. 

8. Rousse, J. M., Ulcerous and Pultaceous Gingivitis. — Mon. d. Hop. 
125. 

9. Guillot, N., Treatment of Muguet. — Rev. Thdr. 

10. Delvaux, Ulcerous Gingivitis of Children. — Jour, de Med. Chir. 
Pharm. April. 

11. Seux, Beport on the Contagiousness of Muguet and on the "Calor- 
icity " in Children. — Bull, des Trav. de la Soc. Imp. de Mars. 3. 

12. Gubler, A., Investigations on the Origin and Development of 
Oidium Albicans, the Fungus of Muguet. — Mdm. de PAc. de Me"d. 
XXII. 

13. Moore, W., Spontaneous Salivation, Cured by Chlorate of Potassa. 
— Dubl. Hosp. Gaz. Aug. 15. • 

14. Corse, Case of Gangrcena Oris, in Summary of the Trans, of the 
coll. of Phys. of Phil. — Am. Jour, of Med. Sc. July. 



343 

15. Montgomery, J. E., Cancrum Ovis. — Nashv.Mour. Med. and Surg. 
Dec. 

16. Bryant, F., Fibrous Tumour Developed within the Lower Jaw 
Surrounding the Dental Nerve. — Trans. Path. Soc. Lond. IX. 

17. Magitot, E., Etude sur le De'veloppement et la Structure des Dents 
Humaines. Accompagne'e de Deux Planches Gravdes. Paris, pp. 
112. (Essay on the Development and Structure of Human Teeth). 

18. Bokai, on Retropharyngeal Abscess in Children. — Jahrb. f. Kind. 
1.4. 

19. Virchow, R., Case of Hydrops Ascites in a Newborn Child. — Mon.- 
Schrift f. Geb. March.— N. Y. Jour, of Med. July. 

20. Thompson, H., Large [Hydatid in the Liver. — Trans. Path. Soc. 
Cond. IX. p. 294. 

21. Luschka, H., on a Large Fibro-Plastic Tumor in the Liver of an 
Infant Four Weeks old. — Virch. Arch. XV. 1, 2. 

22. Morris, J. C, Congenital Malposition of the Liver, in Trans. Coll. 
Phys. Phil. — Amer. Jour. April. 

23. Meyer, G., on the Presence of Sugar in the Liver, in Diseases. — 
Molesch. Unters. IV. 2. p. 119. 

24. Charcot, Rupture of the Spleen in a Foetus. — Gaz. d. Hop.. 144. — 
Gaz. d. Par. 46. 

25. Sibley, S. S., Extensive Tubercular Disease of the Spleen in a 
Child Suffering from Purpura. — Trans. Path. Soc. Lond. IX. p. 
425. Lancet. Sept. 

26. Hauner, Report on the Eleventh Year of the Dispensary of the 
Children's Hospital at Munich. — Journ. f. Kinderkr. 7, 8. 

27. Death from Over-Feeding. — Lancet. Jan. 

28. Wallace, S. W., Letter to the Chicago Medical Journal. — Chic. 
Med. Jour. May. 

29. Royal Free Hospital. — Lancet. Dec. 

30. Maschka, Report on Forensic Examinations. — Prag. Viert. 1. 

31. Schuppert, M., Three Cases of Congenital Deficiency of the Intesti- 
nal Canal. — N. 0. Med. News and Hosp. Gaz. April. 

32. Willshire and Cooper Forster, Fistula of the Colon and Navel. 
Operation. — Med. Times. 399. # 

33. Results of Therapeutical Experiments Made on Pepsine. — Jahrb. 
f. Kind. I. 3. 

34. Wade, W. F., on Lientery in Children — Brit. Med. Jour. Nov. 30. 

35. Guerdau, A., Die Diarrhoea Ablactatorum, Brechruhr und Gastro- 
malacie der Kinder, nebst deren Specifischer Heilmethode. Erklart 
durch R. Virchow's Entdeckung der Leukdmie des Blutes. II. Auf- 
lage. Heilbronn, 1859. pp. 81. — (On Diarrhoea Ablactatorum, In- 
fantile Cholera aud Oastromalacia and their Specific Remedies. Ex- 
plained by R. Virchow's Discovery of Leukaemia.) 

36. Hexamer, A. C, Die Kinder-Cholera oder Sommer-Complaint in 
den Vereinigten Staaten, ihre Natur, Verhutung und rechtzeitige Er- 



344 

kennung. New York. pp. It. — (Cholera infantum or Summer Com- 
plaint in the United States ; its Nature, Prevention, and Early Diag- 
nosis.) 
31. Gholson, R. A., on the Treatment of Cholera Infantum. — Virg. 
Jour. July. 

38. Gholson, R. A., Addenda to the Remarks on Cholera Infantum. — 
Ibid. Aug. 

39. Reid, N. C, Cholera Infantum. — Med. and Surg. Rep. Sept. 

40. Smith, J. L., Report of the Post-mortem Appearances in Eleven 
Cases of Cholera Infantum. — N. Y. Jour, of Med. July. 

41. Schuller, Diarrhoea in the First Year of Life. — Jahrb. f. Kind. 

I. 3. 

42. Weisse, J. W., Raw Beef in the Diarrhoea Ablactatorum. — Journ. 
f. Kinderk. 1, 2. 

43. Ricordeau, J. C, De VEntdrite ChoUriforme Survenant chez I'En. 
fant Nouveau-nd dans les Quinze Premiers Jours de la Naissance- 

Paris, p. 51. — (On Choldriform Enteritis Occurring in Infants dur-. 
ing the First Fortnight after Birth.) 

44. Moore, W., Sugar Treatment in Sepsis and Diarrhoea of Children 
— Dubl. Hosp. Gaz. Aug. 15. 

45. Lederer, Infantile Marasmus, a Result of Chronic Intestinal 
Diseases. — Wien. Med. Woch. 16, It. 

46. Kuttner, on Dystrophia of Children. — Journ. f. Kinderk. 3, 4. 
41. Ferrand, Obstruction of the Intestine in an Infant ; Administration 

of the Metallic Mercury and Eguisier's Irrigator ; Recovery. — Journ. 
d. Bord. Oct. 

48. Caboret, Invagination of the Colon in a Child, Replaced by Le Pel- 
lettier's Method. — Rev. de ther. rndd. chir. 13. 

49. Jacobi, A., Invagination of the Colon Descendens in an Infant, 
with Repeated Hemorrhage in the Colon Transversum. — N. Y. Jour, 
of Med. May. 

50. Mertens, A., Perforation of the Vermiform Process. — Journ. f. 
Kinderk. 3, 4. 

51. Elliot, G. T., Obstetrical and Medical cases. — N. Y. Jour, of Med. 
Nov. 

52. Clar, Catarrh and Follicular Ulceration of the Intestinum Crassum. 
—Jahrb. f. Kind. I, 3. 

53. Clar, Colitis Crouposa. — Ibid. 4. 

54. Clar, Dysentery. — Ibid. 

55. Clar, Constipation. — Ibid. 

56. Constipation for three months completely removed, in Clinical Re- 
cords. — Lancet. Oct. 

51. FOrster, on Meconium. — Wien. Med. Woch. 32. 

58. Debout, on Congenital Umbilical Hernia. — Bull, de l'Ac. Beige. 
1851-1858. I. 4. 

59. Meetings of the "Socidtd de Chirurgie." On Congenital Inguinal 
Hernia. — Un. Me"d. 61. 



345 

60. Extracts from the Records of the Boston Society for Medical Im- 
provement. — Boat. Med. Jour. 

61. Leotaud, A., on Exomphalus in Negro Infants. — Schweiz. Mon. 5. 

62. Transactions of the Obstetrical Society at Berlin. — Monatschr. £ 
Geb. May. 

63. Jones, B. L., a Bandage for Treating Umbilical Hernia and for 
Dressing the Umbilicus of a Newly-Born Infant. — Oglethorpe Med. 
Jour. Dec. 

64. Ravoth, Case of Herniotomy in an Infant. — Monatschrift f. Geb. 
Sept. 

65. Otis, G. A., Strangulated Hernia in Children. — Virg. Jour. March. 

66. Roser, The Theory of Hernice Again. — Arch f. Phys. Heilk. 1. 

61. Richard, A., on the Beneficial Effects of the Employment of Bella- 
donna in Incontinence of Fecal Matters, Existing Alone, or Compli- 
cated with Enuresis, in Children. — Bull. gCn; de ther. Aug. 15. 

68. Bercioux, Belladonna in Enuresis and Involuntary Evacuation of 
Fecal Matters in Children. — Gaz. Hebdom. 25, 28, 30. 

69. Clar, Paralysis of the Spincter Ani. — Jahrb. f. Kind. I. 4. 

10. Magnus, on Prolapse of the Rectum Cured by Local Application 
of Strychnia to the Prolapsed Intestine. — Ugeskrift for Laeger, 
XXXIII. 11. 

11. Holmes, Pedunculated Polypus from the Rectum. — Trans. Path. 
Soc. Lond. IX. p. 212. 

12. Barwell, R., on a Case of Imperforate Anus, with a Peculiar De- 
formity. — Lancet. Oct. 

13. Berend, Atresia Recti. — Mon. d. Hop. II. 

14. Cases of Imperforate Anus. — Brit. Med. Jour. 93. 

15. Senftleben, Reports on Prof Langenbeck?s Surgical Clinique at 
Berlin.— J). Klin. 8. 

16. Bryant, A., Imperforate Anus. — Virg. Jour. April. 

*l*l. Krieger, Some Remarks on Atresia Ani and Uterus Bicornis. — 
Monatschr. f. Geb. Sept. 

18. Davies, R., Proposed Modification of the Operatianfor Imperforate 
Anus. — Ed. Med. Jour. March. — N. Y. Jour, of Med. July. 

19. Elin, Malformation of the Rectum. — Trans. Path. Soc. Lond. IX. 
p. 205. 

80. Jones, J., The Effects of Cathartics in [Imperforate Anus. — N. O. 
Med. and Surg. Jour. Jan. 

81. Meyer, B., Die Wurmlcrankheiten des Menschen mit Versuchen an 
lebenden Thieren. — Zweite Auflage. Leipzig, pp. 131. — (On the 
Worm Diseases of Man, with Experiments on Living Animals.) 

82. Paasch, Tenia Solium in a Child. — Journ. f. Kinderkr. 3, 4. 

83. Diez, Ascarides in the Umbilicus. — Wiirtemb. Corr.-Bl. 12. 

84. Ramskill, E. J. S., on the Use of Rottlera Tinctoria in Tcenia and 
other Intestinal Worms. — Lancet. July. 



346 

85. Moore, W., Cases illustrating the Value of " Kameela " as an Anthel" 
mintic. — Dubl. Hosp. Gaz. May, 1. 

86. Leared, A., on the Use of Kamala as an Anthelmintic. — Lancet. 
July. 

87. Peacock, Imperfect Results from Kameela. — Med. Times and Gaz. 
Nov. 6. 

88. Schultz, C. H , Nitrate of Silver against Helminths in the Rectum. — 
D.Klin. 15 

89. Walter, G., Contributions to the Anatomy and Physiology of 
Oxyuris Ornata. — Z. f. wiss. Zool. VIII. 2. — Giinsb. Zeitschr. II. 

Dr. Neudorfer, after mentioning the well-known fact that the cica- 
trice, after the operation for hare-lip, does not keep pace with the 
growth of the upper lip, recommends transversal incisions through 
the wound in order to elongate the cicatrice to the full length of the 
lip. Dieflfenbach is well known to have, for the like purpose, sepa- 
rated the margin of the lip from the alveolar process. 

Allen Duke operated on four children, whose ages varied from six 
weeks to five months, in the following manner : " The edges pared, 
not in the usual way, but by an oblique incision from before back- 
wards, slightly concave,